Revised and Deleted Questions/Pages from the i3441

About Your Appeal

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- Disability Report - Appeal

Social Security Disability Report -Appeal (Form 3441)

About Your Appeal

1
If you are navigating using only the keyboard or using an assistive
device and need help, visit our instructional waae for alternative
views and navination.
Warning: If you select this link, you will leave this secure site and
go to a new browser window. You will automatically return to this
page when you close the new browser window.

Please answer the following questions to verify where you should be within the Appeal Disability Report process. If
you are unsure of the answers to any of these questions, please contact Social Security for assistance.
The OMB control number for this Internet Appeal Disability Report is XXXX-XXXX; expiration date XlXXXX
Do you live in the United
r yes r NO
States or one of its
territorleslcommonwea Iths? If yes, select one:

Did you receive a Notice of
Decision?
(If vou do not know which
;loice you received, see .
What Is Mv Notice Title?)

C yes

C NO

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Your Appeal" screen
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Your Appeal" screen

If yes, select notice title:

1

.

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* Disability Report - Appeal

I his Internet Disability Report Requires a Printer
(TOcomplete all required steps of this Disability Report, you will need to print, sign, and mail in several forms.
Since you do not have a printer, you cannot use this Internet report. You can use any of the following ways to
complete the Appeal Disability Report:
e

Call our toll-free number, 1800-772-1213. Explain that you are unable to use the online appeal process but do
want to appeal the decision made in your case. tf you are deaf or hard of hearing, call our toll-free "TTY"
number. 18003254778. A representative is available on Monday through Friday fiom 7 a.m. to 7 p.m.
Go to
end tell the representative that you want to appeal the decision made on
your case.
Deleted--SSA no longer requires the use of a printer for the
Internet Appeals screens.

Internet 3441 (Appeal Disability ReporC)
April 22, 2003

Page 11 of 37

Should You Complete This Report?

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said

Disability Report - Appeal

Disability Report - Appeal (Form 3441)

Should You Complete This Report?
Not everyone will be able to complete a Appeal Disability Report online. You must answer all of the following
questions to help determine if you should use this Internet Report or if it would be better for you to speak with a
Social Security representativefirst.
Important:
If you are completing this form for another person, such as a child or client, please note that wherever the questions
ask for information about "you," they are referring to the disabled person.

General Information
What is your Social
Security number?
Please enter your
Social Security
Number with no
dashes.
What is your date of
birth?
Do you have access
to a working
printer ?
If you do not have a
printer, you will not be
able to complete this
form online.

7

1 1 1 1
r

yes

#4--moved to iAppeals "Should
You Use This Internet Appeal
Process" screen

120033

#5--moved to iAppeals "Should
You Use This Internet Appeal
Process" screen

C NO
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Notice of Decision
What is the date on
the " to us
since you received
your "" letter?

3

r

yes

C NO

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#7--moved to iAppeals "Should
You Use This Internet Appeal
Process" screen

Name.
SSN:

Reminder: Contact Us to Get the Request for Appeal
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What You Need to Do:
You need to contact us to determine which appeal form you should complete. Tell the Social Security representative that you are completing this
repon on the Internet, but you dont know which "Request for Appeal" form to complete. You may contact us:

By phone at our toll-free number, 1-8QO-772-1213. Ifyou are deaf or hard of hearing, call our toll-free "TTY" number, 1-800-3254778. A
representative is available Monday through Friday fmm 7 a.m. to 7 p.m.
In person at your local Social Secorii~Officg and pick up a paper form.
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Internet 3441 (Appeal Dbahility Report)
April 22,2003

Page 32 of 37

Reminder to Print Appeal Form

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Disability Report - Appeal

Social Security Disability Report -Appeal (Form 3441)

Reminder: Print the Request for Reconsideration
Based on the date you gave us, you have XX more days to send in the Request for Reconsideration. You may lose
the right to appeal after MMIDDIYYYY. Ignore this reminder if you have already sent this form to Social Security.
What you need to do:

1. Print the Request for Reconsideration form. Use the link below to access the form. When you select the link,
the form will launch in a new browser window. You may close the window after you have printed the form in
order to return to this Disability Report. This form is in Portable Document Format (PDF) and requires Adobe
Acrobat Reader to open it and print it. If you don't have Adobe Acrobat Reader on your computer you can
download it at htt~://access.adobe.com.
2. Complete and sign the form. For instructions on how to complete this form, go to:
http://www.ssa.gov/online/ssa-561 .html
3. Mail it to your local Social Securitv office.

Print one copy.

p
If you have printing problems :
Please try again. If you are still unable to print, please continue. Contact Social Security at the address and phone
number we will give you later to tell us that you could not print the Request for Reconsideration form.

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Reminder to Print Appeal Form

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Page 1 of 1

Disability Report - Appeal

Disability Report -Appeal (Form 3441)

Reminder: Print the Request for Hearing
Based on the date you gave us, you have XX more days to send in the Request for Hearing by Administrative Judge.
You may lose the right to appeal after MMIDDIYYYY. Ignore this reminder if you have already sent this form to Social
Security.
What you need to do:

1. Print the Request for Hearing by Administrative Law Judge form. Use the link below to access the form. When
you select the link, the form will launch in a new browser window. You may close the window after you have
printed the form in order to return to this Disability Report. This form is in Portable Document Format (PDF)
and requires Adobe Acrobat Reader to open it and print it. If you don't have Adobe Acrobat Reader on your
computer you can download it at htt~://access.adobe.com.
2. Complete and sign the form. For instructions on how to complete this form, go to:
http:llwww.ssa.gov/online/ha-501 .html
3. Mail or bring it to your local Social Securitv office.

Print one copy.
HA501 Request for Hearinq bv Administrative Law Judae
If you have printing problems:
Please try again. If you are still unable to print, please continue. Contact Social Security at the address and phone
number we will give you later to tell us that you could not print the Request for Hearing form.

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Page 1 of I

Reminder to Print Appeal Form

Report - Appeal
Social Security Disability Report -Appeal (Form 3441)
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Reminder: Print the Request for Reconsideration Disability
Cessation
Based on the date you gave us, you have XX more days to send in the Request for Reconsideration- Disability
Cessation. You may lose the right to appeal after MMIDDNYYY. Ignore this reminder if you have already sent this
form to Social Security.
What you need to do:
1. Print the Request for Reconsideration - Disability Cessation form. Use the link below to access the form.
When you select the link, the form will launch in a new browser window. You may close the window after you
have printed the form in order to return to this Disability Report. This form is in Portable Document Format
(PDF) and requires Adobe Acrobat Reader to open it and print it. If you don't have Adobe Acrobat Reader on
your computer you can download it at http://access.adobe.com.
2. Complete and sign the form. For instructions on how to complete this form, go to:
http://www.ssa.gov/online/ssa-789.html
3. Mail it to your local Social Security office.

Print one copy.
SSA-789 Request for Reconsideration Disability Cessation

-

If you have printing problems :
Please try again. If you are still unable to print, please continue. Contact Social Security at the address and phone
number we will give you later to tell us that you could not print the Request for Reconsideration - Disability Cessation
form.

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