If you do not agree with the decision or order of an Administrative Law Judge (ALJ) on your claim, you may ask the Appeals Council to review the ALJ's action. To do this, you may use this form or write a letter.
The notice you received will tell you how to appeal the ALJ's decision or order. If the notice says you must request Appeals Council review, this is the form you should use. If the notice does not say this, or you are still not sure this is the form you should complete, call 1-800-772-1213 or your local Social Security Office and they will help you complete the right appeal form.
You must file your appeal within 60 days after the date you got the hearing decision or order. We assume that you got the hearing decision or order within 5 days after the date shown on the notice unless you can show us you did not get it within the 5-day period.
Time to Submit New Evidence
If you have additional evidence submit it with this request for review. If you need additional time to submit evidence or legal argument, you must request an extension of time in writing now. This will ensure that the Appeals Council has the opportunity to consider the additional evidence before taking its action. If you request an extension of time, you should explain the reason(s) you are unable to submit the evidence or legal argument now. If you neither submit evidence or legal argument now nor within any extension of time the Appeals Council grants, the Appeals Council will take its action based on the evidence of record.
How to complete the form
- CLAIMANT NAME: Enter your name or the name of the person on whose behalf you are filing the request for review. Also, enter your Social Security number (SSN) or the SSN of the person on whose behalf you are filing the request for review.
- WAGE EARNER NAME, IF DIFFERENT: If you receive or are applying for Social Security benefits on someone else's work record, enter that person's name.
- CLAIMANT CLAIM NUMBER, IF DIFFERENT: The claimant claim number depends on the type of claim you are appealing. If you are appealing a claim for:
- Social Security benefits on your work record,do not re-enter your SSN.
- Social Security benefits on someone else's work record (that is, the wage earner in 2.), enter that person's SSN.
- Social Security benefits on your work record and on the wage earner's work record, enter the wage earner's SSN but do not re-enter your SSN.
- Supplemental Security Income (SSI), do not re-enter your SSN.
- Social Security benefits on the wage earner's work record and SSI, enter the wage earner's SSN but do not re-enter your SSN.
- SSI only or SSI and Social Security benefits on your work record, enter your husband's or wife's SSN here.
Tell us why you disagree with the hearing decision or order. If you need additional space, you can attach a separate sheet of paper. Include your name and your SSN, and the claimant number if applicable, on any additional pages, and on all correspondence, you send to us.
Do not complete anything below the line that says “THE SOCIAL SECURITY STAFF WILL COMPLETE THIS PART.” We will complete this part of the form when we receive it.