TOE 710

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0622

REQUEST FOR RECONSIDERATION

CLAIMANT SSN

NAME OF CLAIMANT

CLAIM NUMBER (If different than SSN)

ISSUE BEING APPEALED (Specify if retirement, disability, hospital or medical, SSI, SVB, overpayment, etc.)

I do not agree with the Social Security Administration's (SSA) determination and request reconsideration.
My reasons are:

SUPPLEMENTAL SECURITY INCOME (SSI) OR SPECIAL VETERANS BENEFITS (SVB)

RECONSIDERATION ONLY

I want to appeal your determination about my claim for SSI or SVB. I have read about the three ways
to appeal. I have checked the box below.
THREE WAYS TO APPEAL
CASE REVIEW - You can pick this kind of appeal in all cases. You can give us more facts to add to your file.
Then we will decide your case again. You do not meet with the person who decides your case.
INFORMAL CONFERENCE - You can pick this kind of appeal in all SSI cases except for medical issues. In
SVB cases, you can pick this kind of appeal only if we are stopping or lowering your SVB payment. You will
meet with a person who will decide your case. You can tell that person why you think you are right. You can give us
more facts to help prove you are right. You can bring other people to help explain your case.
FORMAL CONFERENCE - You can pick this kind of appeal only if we are stopping or lowering your SSI or
SVB payment. This meeting is like an informal conference, but we can also get people to come in and help prove
you are right. We can do this even if they do not want to help you. You can question these people at your meeting.

CONTACT INFORMATION
CLAIMANT SIGNATURE - OPTIONAL

NAME OF CLAIMANT'S REPRESENTATIVE (If any)

MAILING ADDRESS

MAILING ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER (Include area code) DATE

CITY

STATE

ZIP CODE

TELEPHONE NUMBER (Include area code) DATE

TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION

1. HAS INITIAL DETERMINATION
BEEN MADE?
2. IS THIS REQUEST FILED TIMELY?

FIELD OFFICE DEVELOPMENT (GN 03102.300)

NO FURTHER DEVELOPMENT REQUIRED
No
Yes
REQUIRED DEVELOPMENT ATTACHED
(If "NO", attach claimant's explanation for delay. Refer to
REQUIRED DEVELOPMENT PENDING, WILL
GN 03102.125)
FORWARD OR ADVISE STATUS WITHIN 30 DAYS
SSI CASES ONLY - GOLDBERG KELLY (GK)
SOCIAL SECURITY OFFICE ADDRESS AND DATE
(SI 02301.310) RECIPIENT APPEALED AN ADVERSE
APPEAL RECEIVED
ACTION:
WITHIN 10 DAYS AFTER RECEIVING THE ADVANCE
NOTICE;
AFTER THE 10-DAY PERIOD AND GOOD CAUSE
EXISTS FOR EXTENDING THE TIME LIMIT
PAYMENT CONTINUATION APPLIES AND INPUT
MADE TO SYSTEM
NOTE: Take or mail the completed original to your local Social Security office, the Veterans Affairs Regional Office in
Manila, or any U.S. Foreign Service post and keep a copy for your records.
Form SSA-561-U2 (03-2015) uf (03-2015)
Claims Folder
Prior Edition May Be Used Until Exhausted
Yes

No

ADMINISTRATIVE ACTIONS THAT ARE INITIAL DETERMINATIONS

(See GN03101.070, GN03101.080, and SI04010.010)
NOTE: These lists cover the vast majority of
administrative actions that are initial
determinations. However, they are not all
inclusive.

Title II
1. Entitlement or continuing entitlement to benefits;
2. Reentitlement to benefits;
3. The amount of benefit;
4. A recomputation of benefit;
5. A reduction in disability benefits because benefits
under a worker's compensation law were also
received;
6. A deduction from benefits on account of work;
7. A deduction from disability benefits because of
claimant's refusal to accept rehabilitation services;
8. Termination of benefits;
9. Penalty deductions imposed because of failure to
report 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 deceased
person will be paid;
13. The establishment or termination of a period of
disability;
14. A revision of an earnings record;
15. Whether the payment of benefits will be made, on
the claimant's behalf to a representative payee, u
nless the claimant is under age 18 or legally
incompetent;
16. Who will act as the payee if we determine that
representative payment will be made;
17. An offset of benefits because the claimant
previously received Supplemental Security Income
payments for the same period;
18. Whether completion of or continuation for a
specified period of time in an appropriate v
ocational rehabilitation program will significantly
increase thelikelihood that the claimant will not
have to return to the disability benefit rolls and
thus, whether the claimant's benefits may be
continued even though the claimant is not disabled;
19. Nonpayment of benefits because of claimant's
confinement for more than 30 continuous days in a
jail, prison, or other correctional institution for
conviction of a criminal offense;
20. Nonpayment of benefits because of claimant's
confinement for more than 30 continuous days in a
mental health institution or other medical facility
because a court found the individual was not guilty
for reason of insanity; a court found that he/she
was incompetent to stand trial or was unable to
stand trial for some other similar mental defect; or,
a court found that he/she was sexually dangerous.
Form SSA-561-U2 (03-2015) UF (03-2015)

Title XVI
1. Eligibility for, or the amount of, Supplemental
Security Income benefits;
2. Suspension, reduction, or termination of
Supplemental Security Income benefits;
3. Whether an overpayment of benefits must be
repaid;
4. Whether payments will be made, on claimant's
behalf to a representative payee, unless the
claimant is under age 18, legally incompetent,
or determined to be a drug addict or alcoholic;
5. Who will act as payee if we determine that
representative payment will be made;
6. Imposing penalties for failing to report important
information;
7. Drug addiction or alcoholism;
8. Whether claimant is eligible for special SSI
cash benefits;
9. Whether claimant is eligible for special SSI
eligibility status;
10. Claimant's disability; and
11. Whether completion of or continuation for a
specified period of time in an appropriate
vocational rehabilitation program will
significantly increase the likelihood that
claimant will not have to return to the disability
benefit rolls and thus, whether claimant's
benefits may be continued even though he or
she is not disabled.
NOTE: Every redetermination which gives an
individual the right of further review
constitutes an initial determination.

Title VIII (See VB 02501.035)

1. Meeting or failing to meet the qualifying and/or
entitlement factors for special veterans benefits
(SVB);
2. Reduction, suspension or termination of SVB
payments;
3. Applicability of a disqualifying event prior to
SVB entitlement;
4. Administrative actions in SVB cases similar to
those listed under Title II-items 3, 4, 10, 11 & 16.

Title XVIII
1. Entitlement to hospital insurance benefits
and to enrollment for supplementary
medical insurance benefits;
2. Disallowance (including denial of
application for HIB and denial of
application for enrollment for SMIB);
3. Termination of benefits (including
termination of entitlement to HI and SMI).
4. Initial determinations regarding Medicare Part B
income-related premium subsidy reductions.

TOE 710

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0622

REQUEST FOR RECONSIDERATION

CLAIMANT SSN

NAME OF CLAIMANT

CLAIM NUMBER (If different than SSN)

ISSUE BEING APPEALED (Specify if retirement, disability, hospital or medical, SSI, SVB, overpayment, etc.)

I do not agree with the Social Security Administration's (SSA) determination and request reconsideration.
My reasons are:

SUPPLEMENTAL SECURITY INCOME (SSI) OR SPECIAL VETERANS BENEFITS (SVB)

RECONSIDERATION ONLY

I want to appeal your determination about my claim for SSI or SVB. I have read about the three ways
to appeal. I have checked the box below.
THREE WAYS TO APPEAL
CASE REVIEW - You can pick this kind of appeal in all cases. You can give us more facts to add to your file.
Then we will decide your case again. You do not meet with the person who decides your case.
INFORMAL CONFERENCE - You can pick this kind of appeal in all SSI cases except for medical issues. In
SVB cases, you can pick this kind of appeal only if we are stopping or lowering your SVB payment. You will
meet with a person who will decide your case. You can tell that person why you think you are right. You can give us
more facts to help prove you are right. You can bring other people to help explain your case.
FORMAL CONFERENCE - You can pick this kind of appeal only if we are stopping or lowering your SSI or
SVB payment. This meeting is like an informal conference, but we can also get people to come in and help prove
you are right. We can do this even if they do not want to help you. You can question these people at your meeting.

CONTACT INFORMATION
CLAIMANT SIGNATURE - OPTIONAL

NAME OF CLAIMANT'S REPRESENTATIVE (If any)

MAILING ADDRESS

MAILING ADDRESS

CITY

STATE

TELEPHONE NUMBER (Include area code)

ZIP CODE

CITY

STATE

ZIP CODE

TELEPHONE NUMBER (Include area code) DATE

DATE

TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION

1. HAS INITIAL DETERMINATION
BEEN MADE?
2. IS THIS REQUEST FILED TIMELY?

Yes

No

FIELD OFFICE DEVELOPMENT (GN 03102.300)

NO FURTHER DEVELOPMENT REQUIRED

REQUIRED DEVELOPMENT ATTACHED
(If "NO", attach claimant's explanation for delay. Refer to
REQUIRED DEVELOPMENT PENDING, WILL
GN 03102.125)
FORWARD OR ADVISE STATUS WITHIN 30 DAYS
SSI CASES ONLY - GOLDBERG KELLY (GK)
SOCIAL SECURITY OFFICE ADDRESS AND DATE
(SI 02301.310) RECIPIENT APPEALED AN ADVERSE
APPEAL RECEIVED
ACTION:
WITHIN 10 DAYS AFTER RECIEVING THE ADVANCE
NOTICE;
AFTER THE 10-DAY PERIOD AND GOOD CAUSE
EXISTS FOR EXTENDING THE TIME LIMIT
PAYMENT CONTINUATION APPLIES AND INPUT
MADE TO SYSTEM
NOTE: Take or mail the completed original to your local Social Security office, the Veterans Affairs Regional Office in
Manila, or any U.S. Foreign Service post and keep a copy for your records.
Form SSA-561-U2 (03-2015) uf (03-2015)
Claimant
Prior Edition May Be Used Until Exhausted
Yes

No

HOW TO APPEAL YOUR SUPPLEMENTAL SECURITY INCOME (SSI)

OR SPECIAL VETERANS BENEFIT (SVB) DECISION
Now that you picked the kind of appeal that fits your case, fill out this form or we'll help you fill it out. You can have a
lawyer, friend, or someone else help you with your appeal. There are groups that can help you with your appeal.
Some can give you a free lawyer. We can give you the names of these groups.
NOTE: DON'T FILL OUT THIS FORM IF WE SAID WE'LL STOP YOUR DISABILITY CHECK FOR MEDICAL
REASONS OR BECAUSE YOU'RE NO LONGER BLIND. WE'LL GIVE YOU THE RIGHT FORM (SSA-789-U4)
FOR YOUR APPEAL.
The information on this form is authorized by regulation (20 CFR 404.907 - 404.921 and 416.1407 - 416.1421) and
Public Law 106-169 (section 809(a)(1) of section 251(a)). While your response to these questions is voluntary, the
Social Security Administration cannot reconsider the decision on this claim unless the information is furnished.

Privacy Act Statement

Request for Reconsideration
Section 205(a), of the Social Security Act as amended, [42 U.S.C. 405(a)] and Title 20 C.F.R. 404.907 - 404.922
and 416.1407 -416.1422 authorize us to collect this information. We will use this information to help us determine
your entitlement to benefits. Providing this information is voluntary. However, failing to provide us with all or part of
the requested information may affect our ability to re-evaluate the decision on your claim.
We rarely use the information you provide on this form for any purpose other than for determining problems in Social
Security programs. However, we may use it for the administration and integrity of Social Security programs. We may
also disclose information to another person or to another agency in accordance with approved routine uses, which
include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits
and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and the Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State,
and local level; and;
4. To facilitate statistical research, audit or investigative activities necessary to assure the integrity of Social Security
programs.
We may also use the information you provide in computer matching programs. Matching programs compare our
records with records kept by other Federal, State or local government agencies. Information from these matching
agencies can be used to establish or verify a person's eligibility for Federally-funded or administered benefit
programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of Records Notice entitled Claims
Folder System 60-0089, and 60-0103, Supplemental Security Income Record and Special Veterans Benefits. These
notices, additional information regarding this form, and information regarding our programs and systems, are
available on-line at www.socialsecurity.gov or at any local Social Security office.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. 3507, as
amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless
we display a valid Office of Management and Budget control number. We estimate that it will take about 8 minutes to
read the instructions, gather the facts, and answer the questions.
SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under
U.S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213
(TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd.,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.

Form SSA-561-U2 (03-2015) uf (03-2015)