Who needs a HA-501-U5 form?
This form is completed by the individual who is not satisfied with the decision made by the Social Security Administration or Department of Veteran Affairs.
What is the purpose of the HA-501-U5 form?
This form is a request for a hearing by the administrative law judge of the Social Security Administration’s office of Disability Adjudication. The information in the form is used to initiate a hearing on the individual’s case.
What other documents must accompany the HA-501-U5 form?
The applicant should attach additional evidence regarding his case and this request. In case the applicant wants to be represented at the hearing, he should also submit the SSA-1696 form, Appointment of Representative. If the applicant doesn’t want to be present at the hearing, he should complete the Waiver form HA-4608 (the decision will be made then based on the evidence provided). If the request was delayed, the claimant should include the written explanation and supporting documents.
When is the Request due?
This form is completed and sent to the SSA not later than 65 days after the date of reconsidered determination. The claimant has to provide all the evidence to the hearing office within ten days after sending the request.
The estimated time for completing the form is ten minutes.
What information should be provided in the Request for hearing?
The claimant has to indicate:
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Name
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SSN
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Number of claim
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Reasons for disagreement
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Name and source of additional evidence
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Name of representative
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Residence address
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Phone number
The claimant and the representative also need to date and sign the request.
The Acknowledgement of request for hearing is completed by the Social Security Administration.
What do I do with the request after its completion?
The original copy of the request is sent to the nearest SSA office or Veterans Affairs Regional Office. The claimant should keep one copy for his personal records.
