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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]. We are assuming jurisdiction of the case under our rules.
What We Considered
After receiving exceptions to the Administrative Law Judge's decision, we considered the reasons you disagree with the decision. We also looked at all of the issues considered in the decision whether or not the Administrative Law Judge ruled on them in your favor.
What We Plan To Do
We plan to make a decision finding [State the proposed conclusion of the AC's decision.]
Why We Are Taking This Action
[Enter the rationale for the AC proposed decision. If the decision is partially favorable, explain the basis for the favorable aspect and the unfavorable aspect, e.g., incorporating the ALJ's relevant findings or stating the AC's basis for finding the claimant not disabled prior to the proposed onset date.]
We Will Not Act For 30 Days
You may send us a statement about the facts and the law in this case within 30 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 30 days, we will assume that you do not want to send us more information. We will then make our decision.
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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Administrative Appeals Judge | |
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[Name] | |
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Administrative Appeals Judge |
Enclosure[s]:
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.]