Enter the reason(s) the claimant disagrees with the ALJ’s action. If the claimant needs additional space, the claimant may use a separate sheet of paper and attach a copy to each copy of the Form HA-520-U5.

• •

  Enter the claimant’s address, telephone number, and fax number.

• •

  If the claimant has an appointed representative, enter the representative’s name, address, telephone number, and fax number.

• •

  We do not require a signature to file an appeal. Therefore, the claimant and representative are not required to sign the form. Obtain an SSA-1696-U4 (Appointment of Representative) if the claimant or representative has not previously filed one with us. For information about appointment of a representative, see GN 03910.040.

The employee who prepares or receives the form must complete the box marked for SSA. If an office other than the servicing FO completes it, annotate the FO code with a brief explanation.

• •

  Show the earliest of the following dates as the date filed:

  1. a. 

     date of in-office filing, or

  2. b. 

     postmark or date-stamp on the Form HA-520-U5, or

  3. c. 

     postmark or date-stamp on the letter, or any other written document, or the date on the fax message or email message that requests or indicates intent to file a request for AC review.

• •

  Enter the servicing FO code.

• •

  Attach any letter, fax, email message, or other written document, that could be construed as a request for AC review or that expresses dissatisfaction with the ALJ action to the claims folder copy of the Form HA-520-U5.

EXCEPTION: If the letter, fax, email message, or other written document is marked “confidential,” do not make the additional copies. The AC determines if the material can be included in the official record.

• •

  Attach the postmarked envelope to the claims folder copy of the Form HA-520-U5, if you use the postmark to establish the date of filing.

Check the appropriate block to indicate whether we received the request for AC review within 65 days of the ALJ’s decision or dismissal. In concurrent claims (title II and title XVI), check “yes” only if the request on both claims is timely. Check “no” when the request on one or both claims is not timely, and specify which one(s) is not.

If you check “no,” obtain a statement that explains that claimant’s reason for late filing and develop for good cause. The claimant can add a good cause statement to the appeal request, such as the HA-520-U5, or submit as a separate written statement. The statement should include the following information:

• •

  claimant’s name and address, and

• •

  reason for the delay

Forward the statement and any development along with claim’s folder copy of the Form HA-520-U5 to the AC. The AC will determine whether the request is timely and whether the claimant has good cause.

Check whether the request for AC review is for initial entitlement, termination, or other.

Check all claim types that apply. If the request for review involves an issue not relating to a claim type (for example; HA auxiliary claims, non-claim cases (such as earnings record postings), denial of waiver of recovery of overpayment) specify the reason next to “Other.”

NOTE: Make only one entry in this section.

The claimant should submit any document(s), or other evidence that the claimant wants the AC to consider, with the AC review. If evidence dated after the ALJ decision is relevant to the period before the ALJ decision, the AC will consider it with respect to the AC review. Otherwise, the AC will return the evidence to the claimant with a notice explaining that the claimant may file a new application with a protective filing date back to the date of the request for review.

1. a. 

   Claimant’s additional evidence

   • •

     Attach any evidence to the “claims folder” copy of the Form HA-520-U5.

   • •

     Annotate “evidence attached” on each copy of the Form HA-520-U5.

   • •

     Annotate the claimant's name and social security number on any evidence that the claimant sends to the FO.

   • •

     If the claimant is unable to submit the additional evidence at the time the claimant files the request for AC review, advise the claimant to forward any additional evidence, marked with the claimant's name and SSN, within 15 days to the address listed in GN 03104.200D.1. of this section.

     1. 1) 

        Describe briefly, in the “Reasons for Disagreement” section, the type of evidence the claimant will submit.

     2. 2) 

        If the claimant submits evidence after filing the request for AC review, annotate the evidence with claimant’s name and SSN and forward it directly to the Office of Appellate Operations (OAO) at the address listed in GN 03104.200D.1. of this section.

   • •

     Do not delay forwarding the request for AC review pending submission of evidence.

2. b. 

   If the claimant's statement or other information indicates any development leads which might permit a favorable decision, record the information on an SSA-5002 (Report of Contact) and attach a copy of it to each copy of the Form HA-520-U5 (except for the claimant’s copy).

Within 1 business day of receiving the HA-520-U5, take the following actions:

1. a. 

   Send the HA-520-U5 and additional evidence by email to DCARO.OAO@ssa.gov or fax to 1-833-509-0814; and

2. b. 

   Mail the HA-520 and additional evidence to the Office of Analytics Review, OAO and Oversight at the below address.

OARO, Office of Appellate Operations

5107 Leesburg Pike

Falls Church, VA 22041-3255

Non-disability request for AC Review

Fax the request for AC review and additional evidence into the Non-disability Repository (NDRED).

Place the request for AC review along with any additional evidence into the paper folder and forward to the address in GN 03104.200D.1.

Give or mail a copy of the form to the claimant.

Give or mail a copy of the form to the claimant's appointed representative. If the claimant is not represented, destroy this copy.

Destroy this copy of the form.

Send a copy of the form to the ALJ who conducted the hearing. Destroy this copy if there is a legible copy of the request for AC review in the certified electronic folder (disability appeals) and NDRED (non-disability appeals).