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SOCIAL SECURITY ADMINISTRATION _____________________________________________________________ | |
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Refer to: TAHB [SSN] [XSSN] |
Office of Hearings and Appeals 5107 Leesburg Pike Falls Church, VA 22041-3255] | |
Last Update: 9/1/05 (Transmittal II-6-13)
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SOCIAL SECURITY ADMINISTRATION _____________________________________________________________ | |
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Refer to: TAHB [SSN] [XSSN] |
Office of Hearings and Appeals 5107 Leesburg Pike Falls Church, VA 22041-3255] | |
[Representative's First Name, Middle Initial and Last
Name]
[Address]
[City, State
Zip]
Dear [Mr./Ms. [Representative's Last Name]]:
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Re: |
[Claimant's Name] v. Commissioner of Social Security U.S.D.C. for the [selects District, if appropriate] District of [State] [,] [Division] Civil Action Number [enter number] |
This is about the Administrative Law Judge's decision dated [insert date].
[Use in case of an incorrect request for review notice]
The notice attached to that decision was incorrect in telling you that you had 60 days to request review of the decision by the Appeals Council. The correct information concerning the decision is shown below.
[Use in case of an incorrect Sentence 4 notice]
The notice attached to that decision was incorrect in telling you that if you decided not to file exceptions and the Appeals Council did not act on its own motion, the decision would become the final decision of the Commissioner. You were also informed that beginning the 61st day after the date of the Administrative Law Judge's notice, you had 60 days in which to commence a new civil action. The correct information concerning the decision is shown below.
If You Disagree With The Administrative Law Judge's Decision
Under our rules, you have 20 days to send us a statement about the facts and the law in this case.
We Will Not Act for 20 Days
If you have more information, you must send it to us within 20 days of the date of this letter.
Our address and FAX number are:
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ADDRESS: |
Appeals Council |
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FAX: |
[FAX #], Attn: Branch [#]. |
Put the Social Security Number shown at the top of this letter on your request.
If you send us anything by fax, do not send duplicates by mail. That may delay processing your claim.
What Happens Next
If we do not hear from you within 20 days, we will assume that you do not want to send us more information. We will then prepare a certified copy of the administrative record and send it to the U.S. Attorney to file with the court. If you have questions about the court case, you may contact the district court.
If You Have Any Questions
If you have any questions, you may call or write the Appeals Council. Our telephone number and address are shown at the top of this letter. If you do call, please have this notice with you.
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[Name] | |
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Hearings and Appeals Analyst |
Enclosure:
Self-addressed envelope
cc:
[Claimant's
Name]
[Address]
[City, State
Zip]
[If claimant is unrepresented, letter will be addressed to claimant and “cc” will be deleted.]