II-6-6-16. SAMPLE Attachment to COR 23A

REQUEST FOR DESIGNATION AS A SUBSTITUTE PARTY
IN A PROCEEDING PENDING BEFORE THE APPEALS COUNCIL

I ask to be designated a substitute party in the claim filed by ________________________

on the record of _________________________ Social Security No. ___________________.

I understand that this case is before the Appeals Council.

It has been explained to me that the Appeals Council's action on this case may or may not affect my interest.

I am providing the following information in support of my request:

( ) I have filed a claim as a survivor of the deceased.

( ) I am a surviving heir of the deceased. My relationship is ______________.

( ) I am a legal representative of the estate of the deceased. I am submitting evidence of appointment with this form.