SSA-561-U2 with OMB Approved Changes from 8/2006

Form Approvod

SOCIAL SECURITV ADMINISTRATION

TOE 710

ClMR

(DO nor wrire m

REQUEST FOR RECONSIDERATION
NAME OF CLAIMANT

NAME OF WAGE EARNER OR SELF-EMPLOYED
PERSON (/f d~fferenrfrom claimenr.l

SOCIAL SECURITY CLAIM NUMBER

SUPPLEMENTALSECURITY INCOME lSSIl OR SPECIAL
VETERANS BENEFLTScsvel CLAIM NUMBER

SPOUSE'S NAME (Con7plere ONLY in SSI cases)

rh/s space]

SPOUSE'S SOCIAL SECURITY NUMBER

(Complefe ONLY in SSI coscs)

,

-

I
-CLAIM FOR (Specify rype. e.g., retlrcrnen(, disabillry,
~ospirajinsurance,SSI, SVB, crc. )
-A

..

.

-

.

I do n o t agree with Khe dGerminaion rnadc on tho above claim and request reconsiderarian. My reasons are:

SUPPLEMENTAL. SECURITY INCOME OR SPECIAL VETERANS EENEFlTS RECONSIDERATION ONLY
(Sao the h r w r a y 8 to q~pcalIn the Flow To Appeal Y w r S~pDkmclltalSccurnly Incorn. ISSI) Or Spec~olVclerene BcrreT~tlSVOI Dacle~onl~lrerruct~onr
I
-1 want to appeal your deciaion about my claim for Supplemental Security Ineonre (SSO or Spaclel Vetorana Boneflta
(SVB). I've reed about the three ways to eppoal. I've checked the box bolow."
-Case Review
Informal Conference
Formal Conference

-:

:-:

EITHER THE CLAIMANT OR REPRESENTATIVE SHOULD SIGN - ENTER ADDRESSES FOR BOTH
I declare under penalw of ~0riur-qthat I have examined all the information on this form, and on any accompanying
. - $Tatemants cr
.forms,
. . . . . and
. . . .it. is. .b.u. e. .and
. . .corrdct'to
. . . . . . . . tho
. . . best
. . . . of. . m. .y. knowledgo.
.......
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - a

[SIGNATURE

CLAIMANT SIGNATURE

MAILING ADDRESS

- -_,

-

OR NAME OF CLAIMANT'S REPRESENTATIVE
I
,
NON-ATTORNEY
-1 ATTORNEY

:MAILING ADDRESS
I

- - - - - - - - - - - - - - - - - - - - - *

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CITY

~ A T E

'ZIP CODE

I

I

'CITY

t

- - - - - - - - - . - - - I . - - - - - - - J - - - - - - - - L _ , - - L

TELEPHONE NUMBER Ilncludc wee code1

:STATE

:ZIP CODE

I

I

------------

,--------------------A----------

TELEPHONE NUMeER //nc/u#e ereo codel

:DATE

,

FATE

I

I

TO BE COMPLETED BY S O C I A L SECURITY A D M I N I S T R A T I O N
See list o f initial determinations
1. HAS INITIAL DETERMINATION

BEEN

MADE?

--

;-: YES

--

;-1

NO

-:-I
--

2. CLAIMANT INSISTS
ON FILING

:-:

3. IS THIS.REQUEST FILED TIMELY?
Ilf "NO", arrach oloiment's oxplanorion for dcley and srrech only perrinenf lerrcr. rnarcrjal, or

VES
YES

-:,: NO
-;-: NO

informetian in soclal securiry office.)

RETIREMENT AND SURVIVORS RECONSIOERATIONS ONLY (CHECK ONE) REFER TO IGN 03102.1251

--

- ,
I

--

:,:

,

NO FURTHER DEVELOPMENT REQUIRED

.

DEVELOPMENT PENDING, WILL FORWARD OR ADVISE STATUS
WITHIN 30 DAYS

I-I
REQUIRED
L-'

(GN 03102.3001

REQUIRED DEVELOPMENT ATTACHED

ROUTING
INSTRUCTIONS

1

:

(CHECK ONE) '
-------3

0 DISABILITY DETERMINATION
SERVICES (ROUTE WITH
OlSABlLITV FOLDER)

0 0 0 0 . BALTIMORE
.

a

PROGRAM SERVICE CENTER
010. BALTIMORE

0 OEO. BALTIMORE

.

NOTE: Take or mail the signed original to your local Social Security office,
U.S. Forcign Service p o s t a n d keep a ccpv for your records.
Form SSA-561-U2 (7-2003)EF 11-2005) Destroy Prior Edirions

SECUR'TY OFFICE
ADDRESS'

1
I
0 RECONSIDERATION
DISTRICT OFFICE

-' '

& - I

CENTRAL PROCESSING
SITE ISVB)

the Veterans Affairs Regional Office in Manila or any
Claims Folder

ADMINISTRATIVE ACTIONS THAT AFU3 INITIAL DETERMINATIONS
(See C;N03101.070, GN03101.080, and SI04010.010)
NOTE: These lkrs cover the vast majority of administrative actions that are initial detcrmhtions.
However. hey are not all incIu9ive.

Title II

.

1 Entidement or continuing cnrirlemcnt to benefits;
2. Keentidement to bencfiu;
3. The amount of h e f i r ;
4. A recornputadon of benefit;
5. A reduction in disability b e n e f i ~because benefit<
under a worker's compensation law werc also
received:
6 . A deduction from b e n e f i ~on account of work;
7. A deducrion from disability benefits becausc of
clsimant's refusal. to accept rehabilimtion
services;
8. Termination of bencfirs;
9. Penalty deductions imposed because of failurc to
report cemin events:
10. Any olrerpaymenror mderpaymenr of benefits:
11. Whether an ovcrpaymcnr of huefirsmust be
repaid;
12. How
mderpayrnent of beneliu due a demscd
person will bc paid;
13. The esrablishmenr or rerrninauon of a period of
disability;
14. A revision of an earnings record;
15. Wherber the: payment of benefirc will be
on
the claimant's behalf to a represcnrarivc payee.
unless b e claimant is under age 18 or legally
incomplcnt:
16. Who will acc as rhe payee if we derermine that
representative payment will be m d c :
17. An ofhrr of benefin because thc: claimant
previously rcceived Supplemcnral Security
Incomc pymrnts for the same pcriod;
18. Wherher completion of or conrinu;lcion for a
spcified period of time in an appropriate
vocational rehabiliration program will
significantly incrlase the likelihood bar thc
claimant will not have to return to the disability
benefit rolls and thus, whcrher the claimant's
benefits may be continued even rhough rhe
claimant ib; not disabled;
19. Nonpayment of benefits because of claimant's
conhement for more ban 30 ~ n r i n u o u sdays in
a jail, prison, or other correctional instituGon for
convicrion of a criminal offense;
20. Nonpayment of benefic$ becausc of claimant's
confinement for more than 30 conlinuous days in
a mental health institution or orher medical
facilily becausc a court found thc individual was
not guilty for rcaron of insanity; a court found
that hclshe was incompc~enrto stand trial or w a s
~ b l toe stand trial for some other s i m k mental
defect; or, a court found that helshc was scxually
dangerous.
Form SSA-561-U2 17-20031 EF (1-2005)
Destroy Prior Editions

Title XVI
1. Eligibility for, or [he ,mount of. Supple
m c m l Securiry Income b-nefits;
2. S u s p s i o n , rcduaion, or termination of
Supplemental Srcuriry Income bc~efits;
3. Whcther .XIoverpaymen1of benefits must be
repaid;
4. Whcrher payments will be made, on
clainxant's behalf KO a. representative
payee, unless
cla.hmr is u d c r age 18,
legally incompeten~,or determined to be a
d r y addict or alcoholic:
5. Who will act as payee if wc determine h r
representative payment will be made;
6. Imposing penalties for failing to reporr
importat information;
7. Drug addiction or alcoholism;
8. Whether claimant is eligible for special SS1
caqh kncfin;
9. Whether claimant is eligiblc for spccial SSl
eligibility starus;
10. Claimanr's disability; and
11. Whcrher completion of or ~0IltiII~tioLI
for a
specified period of time in an appropriate
vocational rehabilitation program will
significantly increase the likelihood h a t
claimant will not have to rcrum to the
disability benefit rollfi .ad thus, whcther
claimant's benefits may be continued even
thou@ he or she is not disabled.

NOTE: Every redeterminarion which gives an
inclividual the right of furthcr review
constirutes 'an initial determination.

Title VIII (See VB 02501.035)
1. Meeting or failing to meet the qualifying
mdjor mtirlemcnt factors for spccial
ve[crans bcnefits (SVB):
2. Reduclion, suspcnsion or termination of SVB
papmenu ;
3 . Applicability of a disqualifying event prior to
SVB ~atitlern~nt:
4. Adminisrrarive actions in SVB cases similar
to those lined under Ti~lcTI--items3. 4, 10,
11 & 16.

Title XVXII
1. Bntitlcmenr to hospital insurance benefits and
lo enrolhcnt for supplemenury medical
insurance hc-firs;
2. Disdlow,mcc (including denial of application for HIB and denial of application for
enrollment for SMIB):
3. 'fernhadon of k ~ e f i r (including
s
terminalion of mcitlemenl to HI and SMl).

p&B

L - @ & k
TOTAL F. 00.3
P.03

Form Approvod
SOCIAL SECURITY AOMlNlSTRATlON

TOE 710

[Do nor wrire in thls space)

REQUEST FOR RECONSIDERATION
NAME OF CLAIMANT

NAME OF WAGE EARNER OR SELF-EMPLOYED
PERSON /I/ differenr from claimrrnr.1

SOCIAL SECURITY CLAIM NUMBER

SUPPLEMENTAL SECURITY INCOME lSSI1 OR SPECIAL
VETERANS BENEFITS csvel CLAIM NUMBER

SPOUSE'S NAME (Conlpfere ONLY in SSI cases)

SPOUSE'S SOCIAL SECURITY NUMBER
'
/Cornp/e~eON1 Y in SSI coscs)

-CLAIM FOR (Speu'fy rype. e.g., rerlrcmenr, disabillry, ~ospiraJin~urance,SSI. SVB, crc.)

- --

.

Ac.--,

I do n o t agree with the detorminarian made on the above,claim and requcsr reconsideration. My reasons are:

_______

- _ - _ _. - _ . _ - . - - - - _ - - - - - - - _ . - - - - . - - - -

-

-

-

-

-

---_-

-

-

-

-

-

/

- - - - .. - - - - - - - - -

-

-

-

-

----

.----

-

SUPPLEMENTAL SECURITY INCOME OR SPECIAL VETERANS RENEFlTS RECONSIDERATION ONLY
Secur~ryIncome ISSI) Or Spec101Vecerens &ncl~t (SVBI Deoa~onl~lierructlonsI
(Soo the mroo r*aya to appeal in the How To Appeel Y a r r Sup~lcrncr~tal
'1 want to appeol your decision abour my deim for Supplemental Security Income (SSII or Spaclel Vetorane BoneflIa
(SVBI. I'vo reed about the three ways
- to appeal, I've checked the box bolow."
L -II Case Review
I
lnforrnal Conference
Formal Conference

--

EITHER THE CLAIMANT

:-:-

[:I

OR REPRESENTATIVE SHOULD SIGD - ENTER ADDRESSES FOR BOTH

I declare under penalty of parjury that I have examined all the information on this form, and on any accompanying statemants or
.forms,
. . . . . and
. . . .~t. IS
. .u. u. e. .and
. . . correct
. . . . . .t.o. tho
. . . .best
. . . .of. .m. y. .knowledgo.
......
----------------------------------------------.

.-_,

-

CLAIMANT SIGNATURE

[SIGNATURE OR NAME OF CLAIMANT'S
REPRESENTATIVE
- I
I
NON-ATTORNEY
ATTORNEY

MAILING ADDRESS

:MAILING ADDRESS

I

:-:

--.-------------------------------------------.

......................
ClTV

------------&--.-------------------------------------------

:STATE

:ZIP CODE

I

I

tClTV

t

- - , - , - - - - . - - - - - - - - - - - - d - - - - - - - - - - - - L -

:DATE

TELEPHONE NUMBER /lncludc w e e cede)

TELEPHONE NUMEER (lnctr/de area

,

:ZIP CODE

'STATE

PATE

1

I

--

-:

--

:-:
--

I

(If "NO", atrech claimant's axplanarion for dclay end srrsch only pertinent lerrcr, marcriel, or
informelion in soclal securiry office.)
SECURIN

RETIREMENT AND SURVIVORS RECONSIOERATIONS ONLY (CHECK ONE) REFER TO (GN 03102.1 251

-I

I

;-:
' - I
'

.

L-'

N O FURTHER DEVELOPMENT REQUIRED

YES
I

.-,
YES

3. I S THIS REQUEST FILED TIMELY?

,
--

------------

catie~

TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION
See list of initial determinstions
INSISTS
1. HAS INITIAL DETERMINATION
; YES ;-1 NO 2. CLAIMANT
ON F,L,NG
BEEN MADE?

-

I

I
_ - - - - , - , - - - - - - - - - - - - - - L - -

-.:,I

NO

:-:

NO

OFFICE

ADDRESS'

IGN 03102.300l

REQUIRED DEVELOPMENT ATTACHED
REQUIRED DEVELOPMENT PENDING, WILL FORWARD OR ADVISE STATUS
WITHIN 30 DAYS
I

ROUTING
INSTRUCTIONS
(CHECK ONE)

:: ,gSERVICES
DISABILITY DETERMINATION
(ROUTE WITH

- - - - - - -3 '1

OISABlLITY FOLDER)
ODO.,BALTIMORE

PROGRAM SERVICE CENTER

0010. BALTIMORE
0 OEO. BALTIMORE

I

I

0 DISTRICT
OFFICE
RECONSIDERATION
I

L

-

I
I

CENTRAL PROCESSING
SITE iSVBI

NOTE: Take or mail rhe signed original to your local Social Security office. the Veterans Affairs Regional Office in Manila or any
U . S . Forcign Service posr and keep a copv far your records.
Form SSA-561.U2 (7-20031 EF (1-20051 Desrroy Prior Editions
C l a i m s Folder

HOW TO APPEAL YOUR SUPPLEMENTAL SECURITY INCOME (SSI)
OR SPECIAL VETERANS BENEFIT (SVB) DECISION
There are three different ways to appeal. You can pick the appeal that fits your case. You can have a lawyer,
friend, or someone else help you with your appeal.
Here are the three ways to appeal:
1. CASE REVIEW:

You can give us more facts to add to your file. Then we'll decide your case again. You don't meet with the
person who decides your case.
You can pick this kind of appeal in all cases.

2. INFORMAL CONFERENCE:
You'll meet with the person who will decide your case. You can tell that person why you
think you're right. You can give us more facts to help prove you're right. You can bring other people to
help explain your case.
You can pick this kind of appeal in all SSI cases except two. You can't have it if we turned down your SSI
application for medical reasons or because you're not blind. Also you can't have it if we're giving you SSI
but you disagree with the date we said you became blind or disabled. In SVB cases, you can pick this kind
of appeal only if we're stopping or lowering your SVB payment.
3. FORMAL CONFERENCE:
This is a meeting like an informal conference. Plus, we can make people come to help prove you're right.
We can do this even if they don't want to help you. You can question these people at your meeting.
You can pick this kind of appeal only if we're stopping or lowering your SSI or SVB payment. You can't
get it in any other case.
Now you know the three kinds of appeals. You can pick the one that fits your case. Then fill out the front of
this form. We'll help you fill it out.
There are groups that can help you with your appeal. Some can give you a free lawyer. We can give you the
names of these groups.
NOTE: DON'T FILL OUT THIS FORM IF WE SAID WE'LL STOP YOUR DISABILITY
CHECK FOR MEDICAL REASONS OR BECAUSE YOU'RE NO LONGER BLIND.
WE'LL GIVE YOU THE RIGHT FORM (SSA-789-U4) FOR YOUR APPEAL.
The information on this form is authorized by regulation (20 CFR 404.907-404.92 1, 4 16.1407416.142 1,408.1009), Public Law 106-169 (section 809(a)(l) of section 25 l(a)), and the Social
Security Act (Title XVIII (1869(b)). While your response to these questions is voluntary, the
Social Securitv Administration cannot reconsider the decision on this claim unless the

d
ents of 44 U.S.C. 5

Form SSA-56142 ( 7 - 2 0 0 3 ) EF ( 1 - 2 0 0 5 )
Destroy Prior Editions

Thefollowing revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. 8 3507, as amended by section 2 of the Paverwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 8
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213. You may send comments
on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
Send&o comments relating to our time estimate to this address, not the completed
form.