Request for Reconsideration - SSA-561-U2

1 SUPPLEMENTAL SECURITY INCOME (SSI) ORSPECIAL VETERANS BENEFITS (SVB) CLAIMNUMBERNAME OF WAGE EARNER OR SELF-EMPLOYEDPERSON(If different from claimant.)SPOUSE'S NAME(Complete ONLY in SSI cases)CLAIM FOR(Specify type, , retirement, disability, hospital /medical, SSI, SVB, etc.)SOCIAL SECURITYADMINISTRATIONTOE 710 TELEPHONE NUMBER(Include area code)TELEPHONE NUMBER(Include area code)( ) - ( ) - ODO, BALTIMOREOIO, BALTIMOREPROGRAM SERVICE CENTEROEO, BALTIMOREForm ApprovedOMB No. 0960-0622(Donotwriteinthisspace)SOCIAL SECURITY OFFICE ADDRESSNOTE:Take or mail thesigned originalto your local Social Security office, the Veterans Affairs Regional Office in Manila or Foreign Service post and keep a copy for your CLAIMANT INSISTSON FILING1. HAS INITIAL DETERMINATIONBEEN MADE?

2 3. IS THIS Request FILED TIMELY?(If "NO", attach claimant's explanation for delay and attach any pertinent letter, material, orinformation in SocialSecurity office.)CLAIMANT SIGNATURETOBECOMPLETEDBYSOCIALSECURITYAD MINISTRATIONS eelistofinitialdeterminationsRETIREMENT AND SURVIVORS RECONSIDERATIONS ONLY (CHECK ONE) REFER TO (GN )ROUTINGINSTRUCTIONS(CHECK ONE)MAILING ADDRESSCITY STATE ZIP CODE - DATECENTRAL PROCESSINGSITE (SVB)DISTRICT OFFICERECONSIDERATIONI declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements orforms, and it is true and correct to the best of my ADDRESSCITY STATE ZIP CODE - DATEC laims FolderREQUIRED DEVELOPMENT ATTACHEDREQUIRED DEVELOPMENT PENDING, WILL FORWARD OR ADVISE STATUSNO FURTHER DEVELOPMENT REQUIRED (GN )

3 YESNONOYESYESNOWITHIN 30 DAYS - - SPOUSE'S SOCIAL SECURITY NUMBER(Complete ONLY in SSI cases)NAME OF CLAIMANTREQUEST FOR RECONSIDERATIONATTORNEYNON-ATTORNEYSIGNA TURE OR NAME OF CLAIMANT'S REPRESENTATIVEI nformal ConferenceCase ReviewFormal ConferenceEITHER THE CLAIMANT OR REPRESENTATIVE SHOULD SIGN - ENTER ADDRESSES FOR BOTHI do not agree with the determination made on the above claim and Request Reconsideration . My reasons are:SUPPLEMENTAL SECURITY INCOME OR SPECIALVETERANS BENEFITS Reconsideration ONLY(See the three ways to appeal in the How To Appeal Your Supplemental Security Income (SSI) Or Special Veterans Benefit (SVB) Decisioninstructions.)"I want to appeal your decision about my claim for Supplemental Security Income (SSI) or Special Veterans Benefits(SVB).

4 I've read about the three ways to appeal. I've checked the box below."DISABILITY DETERMINATIONSERVICES(ROUTE WITHDISABILITY FOLDER)CLAIMANT SSN - - - - - - CLAIMANT CLAIM NUMBER(if different from SSN)FormSSA-561-U2(9-2007)ef(9-2007)Prio rEdition MayBe Used Until ExhaustedFormSSA-561-U2(9-2007) ef (9-2007)Title IITitle VIII(See VB )ADMINISTRATIVE ACTIONS THAT ARE INITIAL DETERMINATIONS(See , , and )NOTE: These lists cover the vast majority ofadministrative actions that are initialdeterminations. However, they are not : Every redetermination which gives anindividual the right of further reviewconstitutes an initial Entitlement or continuing entitlement to benefits;2. Reentitlement to benefits;3. The amount of benefit;4. A recomputation of benefit;5.

5 A reduction in disability benefits because benefitsunder a worker's compensation law were alsoreceived;6. A deduction from benefits on account of work;7. A deduction from disability benefits because ofclaimant's refusal to accept rehabilitation services;8. Termination of benefits;9. Penalty deductions imposed because of failure toreport certain events;10. Any overpayment or underpayment of benefits;11. Whether an overpayment of benefits must be repaid;12. How an underpayment of benefits due a deceasedperson will be paid;13. The establishment or termination of a period ofdisability;14. A revision of an earnings record;15. Whether the payment of benefits will be made, onthe claimant's behalf to a representative payee,unless the claimant is under age 18 or legallyincompetent;16.

6 Who will act as the payee if we determine thatrepresentative payment will be made;17. An offset of benefits because the claimant previouslyreceived Supplemental Security Income paymentsfor the same period;18. Whether completion of or continuation for aspecified period of time in an appropriate vocationalrehabilitation program will significantly increase thelikelihood that the claimant will not have to return tothe disability benefit rolls and thus, whether theclaimant's benefits may be continued even thoughthe claimant is not disabled;19. Nonpayment of benefitsbecause of claimant'sconfinement for more than 30 continuous days in ajail, prison, or other correctional institution forconviction of a criminal offense;20. Nonpayment of benefitsbecause of claimant'sconfinement for more than 30 continuous days in amental health institution or other medical facilitybecause a court found the individual was not guiltyfor reason of insanity; a court found that he/she wasincompetent to stand trial or was unable to stand trialfor some other similar mental defect; or, a courtfound that he/she was sexually XVI1.

7 Eligibility for, or the amount of, SupplementalSecurity Income benefits;2. Suspension, reduction, or termination ofSupplemental Security Income benefits;3. Whether an overpayment of benefits must berepaid;4. Whether payments will be made, on claimant'sbehalf to a representative payee, unless theclaimant is under age 18, legally incompetent,or determined to be a drug addict or alcoholic;5. Who will act as payee if we determine thatrepresentative payment will be made;6. Imposing penalties for failing to reportimportant information;7. Drug addiction or alcoholism;8. Whether claimant is eligible for special SSI cashbenefits;9. Whether claimant is eligible for special SSIeligibility status;10. Claimant's disability; and11. Whether completion of or continuation for aspecified period of time in an appropriatevocational rehabilitation program willsignificantly increase the likelihood thatclaimant will not have to return to the disabilitybenefit rolls and thus, whether claimant'sbenefits may be continued even though he orshe is not Meeting or failing to meet the qualifying and/orentitlement factors for special veterans benefits(SVB);2.

8 Reduction, suspension or termination of SVBpayments;3. Applicability of a disqualifying event prior toSVB entitlement;4. Administrative actions in SVB cases similar tothose listed under Title II--items 3, 4, 10, 11 & XVIII1. Entitlement to hospital insurance benefitsand to enrollment for supplementarymedical insurance benefits;2. Disallowance (including denial ofapplication for HIB and denial ofapplication for enrollment for SMIB);3. Termination of benefits (includingtermination of entitlement to HI and SMI).4. Initial determinations regarding MedicarePart B income-related premium SECURITY INCOME (SSI) ORSPECIAL VETERANS BENEFITS (SVB) CLAIMNUMBERNAME OF WAGE EARNER OR SELF-EMPLOYEDPERSON(If different from claimant.)SPOUSE'S NAME(Complete ONLY in SSI cases)CLAIM FOR(Specify type, , retirement, disability, hospital/medical, SSI, SVB, etc.)

9 SOCIAL SECURITYADMINISTRATIONTOE 710 Form ApprovedOMB No. 0960-0622(Donotwriteinthisspace) - - - - SPOUSE'S SOCIAL SECURITY NUMBER(Complete ONLY in SSI cases)CLAIMANT SSN - - NAME OF CLAIMANTREQUEST FOR RECONSIDERATIONI do not agree with the determination made on the above claim and Request Reconsideration . My reasons are:ODO, BALTIMOREOIO, BALTIMOREPROGRAM SERVICE CENTEROEO, BALTIMORENOTE:Take or mail thesigned originalto your local Social Security office, the Veterans Affairs Regional Office in Manila or Foreign Service post and keep a copy for your (CHECK ONE)FormSSA-561-U2(9-2007)ef(9-2007)Prio rEdition MayBe Used Until ExhaustedCENTRAL PROCESSINGSITE (SVB)DISTRICT OFFICERECONSIDERATIONC laimantDISABILITY DETERMINATIONSERVICES(ROUTE WITHDISABILITY FOLDER)3.

10 IS THIS Request FILED TIMELY?(If "NO", attach claimant's explanation for delay and attach any pertinent letter, material, orinformation in SocialSecurity office.)RETIREMENT AND SURVIVORS RECONSIDERATIONS ONLY (CHECK ONE) REFER TO (GN )NOYESSOCIAL SECURITY OFFICE ADDRESSREQUIRED DEVELOPMENT ATTACHEDREQUIRED DEVELOPMENT PENDING, WILL FORWARD OR ADVISE STATUSNO FURTHER DEVELOPMENT REQUIRED (GN )WITHIN 30 DAYS( ) - ( ) - TELEPHONE NUMBER(Include area code)TELEPHONE NUMBER(Include area code)MAILING ADDRESSMAILING ADDRESS2. CLAIMANT INSISTSON FILING1. HAS INITIAL DETERMINATIONBEEN MADE?TOBECOMPLETEDBYSOCIALSECURITYADMINI STRATIONS eelistofinitialdeterminationsCITY STATE ZIP CODE - DATECITY STATE ZIP CODE - DATEYESNONOYESCLAIMANT SIGNATUREI declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements orforms, and it is true and correct to the best of my OR NAME OF CLAIMANT'S REPRESENTATIVEEITHER THE CLAIMANT OR REPRESENTATIVE SHOULD SIGN - ENTER ADDRESSES FOR BOTHI nformal ConferenceCase ReviewFormal ConferenceSUPPLEMENTAL SECURITY INCOME OR SPECIALVETERANS BENEFITS Reconsideration ONLY(See the three ways to appeal in the How To Appeal Your Supplemental Security Income (SSI) Or Special Veterans Benefit (SVB) Decisioninstructions.)