Last Update: 9/1/05 (Transmittal II-6-13)
REQUEST FOR DESIGNATION AS A QUALIFIED INDIVIDUAL
IN A PROCEEDING
PENDING BEFORE THE APPEALS COUNCIL
I ask to be designated a qualified individual 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 am the surviving eligible spouse of the deceased.
( ) I am the surviving spouse of the deceased and was living in the same household as the deceased in the month he or she died or within 6 months immediately preceding the month of death.
( ) I am the parent of the deceased disabled or blind child who was living with me at the time of death or within the 6 months immediately preceding the month of death.
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