SSA-561-U2

Claimant's Name

What is your name?

Phone Number

What is your phone number?

Address

Street address (street number and name only):

City:

State:

ZIP code:

Claim Number

What is your social security number?

Is your claim number DIFFERENT from your social security number? (Not typical)

Is your claim number DIFFERENT from your social security number? (Not typical) YesNo

The claim number can be found on the initial determination from the SSA.

What is your claim number?

Issue Being Appealed

What is your case about?

What is your case about? RetirementDisabilityHospital/MedicalSSISVBOverpaymentOther

Please specify the issue being appealed:

Appeal Type

Is your appeal related to SSI or SVB?

Is your appeal related to SSI or SVB? YesNo

Choose the type of appeal you are initiating:

Choose the type of appeal you are initiating: Case Review (most common)Informal Conference (to meet with the SSA)Formal Conference (to meet with the SSA in a legal proceeding)

Reasons For Appeal

Briefly describe why you disagree with the SSA's determination:

Enter a maximum of 350 characters (approximately 2-3 sentences).

Representative

Have you appointed someone to help you with social security matters?

Have you appointed someone to help you with social security matters? YesNo

Representative's name:

Phone number:

Street address (street number and name only):

City:

State:

ZIP Code:

Signature

Do you want to sign the form now?

Do you want to sign the form now? YesNo

Please draw your signature:

Clear

Please draw your signature.

Select today's date:

Save and finish later