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 that relates to the period on or before the date of the hearing decision, you must inform the Appeals Council about it or submit it. If you have a representative, then your representative must help you obtain the evidence unless the evidence falls under an exception. You may also submit any other additional evidence to the Appeals Council. 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 submit neither evidence nor legal argument now or within any extension of time the Appeals Council grants, the Appeals Council will take its action based on the evidence currently in your file.
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.
- CLAIMANT SSN: Enter your Social Security number (SSN) or the SSN of the person on whose behalf you are filing the request for review.
- CLAIM NUMBER (if different than SSN): 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 (a wage earner), enter that person's SSN.
- Social Security benefits on your work record and on another person'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 another person'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.
- I request that the Appeals Council review the Administrative Law Judge's action on the above claim because:
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 claim number if applicable, on any additional pages, and on all correspondence, you send to us.
Please grant me an extension of time to submit evidence or argument: Mark this checkbox to request an extension of time to submit evidence or argument.
- CLAIMANT'S SIGNATURE: Sign and date the form and fill in your address and telephone number. If you are filing on behalf of a child or an incompetent adult, enter your relationship to the claimant (for example, parent or legal guardian).
- REPRESENTATIVE'S SIGNATURE: If you have a representative, he or she should sign and complete this section. Do not delay filing your request for review to get your representative's signature. If you are represented and your representative is unavailable to complete this form, you should also print his or her name and address in this section. If you do not have a representative and would like someone to represent you (for example, an attorney), your local Social Security office can provide you with a list of representatives for your area.
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.