TN 5 (04-21)

GN 03105.070 FO Folder Retrieval Checklist — Exhibit

Identifying data (complete all applicable items):

1. 1. 

   N/H Name:                    SSN:                 

2. 2. 

   Appellant Name (if different):                          

3. 3. 

   Cross reference SSN/BOAN (if any):                

4. 4. 

   Type of Case (circle one):  Hearing   AC Review   Civil Action

5. 5. 

   Hearing Request Date:                 

6. 6. 

   Date HA-501 (HO copy) forwarded to OHO:                

7. 7. 

   Type of Folder(s) Needed (check all applicable):

   ( ) SSI Aged

   ( ) SSI Blind/Disabled

   •  

     ( ) current folder ( ) prior folder

   ( ) T2 DI B

   •  

     ( )current folder ( ) prior folder

   ( ) DWB

   ( ) RSI

8. 8. 

   ( ) Other       

   Query Information(show pertinent information and attach copies):

   1. a. 

      PCACS date:                shows:                

   2. b. 

      SSI2 date:                shows:                

   3. c. 

      HA04 date:                shows:                

   4. d. 

      Other type:                 date:          shows:                

   Field Office Actions

   1. a. 

      Component contacted:                

   2. b. 

      Date of initial request:                

   3. c. 

      Date of follow-up request:                

   4. d. 

      Office making referral:                

   5. e. 

      Office contact person:                

   6. f. 

      Office telephone number:                

   7. g. 

      Date referred to ORC: