Acknowledgement of Receipt (Notice of Hearing) Cover Letter - HA-L83

SOCIAL SECURITY ADMINISTRATION
Refer To: [Clmt SSN]
[Clmt Name]

Office of Disability Adjudication and Review
[Local Office Address]
Tel: [Local Office Phone]/ Fax: [Local office
Fax]
[Current Date]

[Clmt Name]
[Clmt Address]
NOTICE OF HEARING
Please bring this notice of hearing with you to the hearing.
I have scheduled your hearing for:
Day:

[Day]

Date:

[Date]

Time: [Time]

I will conduct your hearing by telephone because we have found that you cannot appear in
person, and video conferencing is not available. On the date and at the time listed above, I will
call you at the telephone number in our file. The number is [Telephone Number]. If this is not the
correct telephone number, please call this office immediately.

Room: [Room]

Address:

[Address]

It Is Important That You , and Your Child,
Attend Your Hearing
I have set aside this time for you to tell me about your case. If you do not attend the hearing
and I do not find you have a good reason, I may dismiss your request for hearing. I may do so
without giving you further notice.

Please bring someone to care for your child, since your child may not need to be present
for the entire hearing.

You must bring valid picture identification (ID) to your hearing. Examples of acceptable
picture ID include a:



Current and valid U.S. State driver’s license;



U.S. State-issued identity card;



Current U.S. passport; or



U.S. military ID/dependent military ID.

If you do not have any of these forms of ID, please bring another form of picture ID with you.
Proper ID is also required for your representative (if you have one), a friend, or a member of
your family who comes with you to the hearing. Without proper ID, you may not be able to
enter the building where your hearing is being held. This could stop or delay your hearing.

Please bring all of your current medications to your hearing.
Please have all of your current medications available for your
hearing.

If you worked since your illnesses, injuries, or conditions began, please havebring all related documents forto your hearing. This includes, but is not limited to, a copy of
your pay stubs and a copy of your tax return for any year(s) worked.

Complete the Enclosed Form
Please complete and return the enclosed acknowledgement form. You must return it within 30
days of the date you get this notice or 5 days before your hearing, whichever is earliest. Please
use the enclosed envelope to return the form to us. We assume you received this notice 5 days
after the date on it unless you show us that you did not get it within the 5-day period.[If claimant
is represented, insert the following language immediately following the language above] We
sent your representative a copy of the acknowledgment form. Your representative also should
return his or her copy of the form.
[If VTC=Yes insert following]The ALJ Plans To Use Video Teleconferencing (VTC) At
Your Hearing
You are scheduled to appear at your hearing by video teleconference (VTC). You will be at
the location shown above during the hearing, and I will be at another location. A large, color
monitor will allow us to see, hear, and speak to each other. I will also be able to see, hear, and
speak to anyone who comes with you to the hearing. This may include your representative (if
you have one), a friend, or a member of your family. A person will be at your location to
operate the equipment and provide any other help you may need.

[If VTC=Yes insert following]What To Do If You Do Not Want To Appear At Your
Hearing By Video Teleconferencing (VTC)
If you do not want to appear at your hearing by VTC, you must let me know within 30 days of
the date you receive this notice or 5 days before your hearing, whichever is earliest. Please do
this by returning the enclosed acknowledgment form and checking the block that says, “I do
not want to appear at my hearing by video teleconference. Please reschedule my hearing so
that I may appear in person.”
If you return the enclosed form within the above timeframe, I will arrange an in-person
hearing for you on the next available hearing date. However, asking me to reschedule your
hearing so you can appear in person might delay your hearing.
If You Cannot Attend Your Scheduled Hearing
If you are not able to attend your hearing at the time and
place I have set, please call this office immediately.

If you need to change the time of your hearing, or place of
your hearing, you must ask for a change no later than 30 days after you receive the
Notice of Hearing. I will rule on your request based on our standards for deciding if there is a
good reason for changing the time and place of a
scheduled hearing. If you delay in asking for a change, I will also decide whether you have a
good reason for the delay.
To request a change you must state why you object to the time or place set for your hearing. You also must state the time and place you want the hearing held. You must do this in
writing.

If you need to change the time of your hearing, or place of
your hearing, you must ask for the change as soon as you know of a problem that will
keep you from attending the hearing, but not later than 5 days before the date set for the
hearing or, if earlier, 30 days after receiving notice of the hearing. Your request must be in
writing to tell me why you need the change and the time and
place you would like the hearing held.
I will decide whether you have a good reason for requesting the change. If you delay in asking
for a change, I will also decide whether you have a good reason for the delay.

If I find you have a good reason for your request, I will set a new time and place for your hearing. I will also send another notice giving you the

new time and place of your hearing at least 75 20 days before the new date of the hearing.

If You Want Help With Your Appeal
You may choose to have a representative help you. We will work with this person just as we
would work with you. If you decide to have a representative, you should find one quickly so
that person can start preparing your case.
Many representatives charge a fee. Some representatives charge a fee only if you receive
benefits. Others may represent you for free. Usually, your representative may not charge a
fee unless we approve it. If you get a representative, you or that person must notify us in
writing.

You May Submit More Evidence and Review Your File
It is very important that the evidence in your file is complete and up-to-date. If there
is more evidence, such as recent records, reports, or evaluations that you want me to see,
you must give it to me no later than 5 business days before the date of your hearing. If
you do not comply with this requirement, I may decline to consider the evidence unless
the late submission falls within a limited exception. If there is more evidence, such
as recent records, reports, or evaluations that you want me to see, please mail or bring that evidence to me as soon as possible. If you cannot submit the evidence to me before the hearing, you
may bring it to the hearing. Submitting evidence to me before the hearing can often
prevent delays in reviewing your case.

If you want to see your file before the date of your hearing, please call this office and make
arrangements. If your file is electronic, you may ask for a copy on a compact disc. You may also review your file on the day of your hearing if
you come in at least 30 minutes before the time set for your hearing. Please call us in advance
if you will need more than 30 minutes to review your file.

:
Issues I Will Consider

The hearing concerns your application of [Title II AppDate], for a Period of Disability and Disability Insurance
Benefits under sections 216(i) and 223(a) [Title XVI AppDate], for
Supplemental Security Income (SSI) under section 1614(a)(3) of the Social Security
Act (the Act). The hearing also concerns your application of
[Title XVI AppDate], for Social Security Income (SSI). I will consider whether you
are disabled under sections 216(i) and 223(d) section 216(i), section 223(d), and section 1614(a)(3) section
1614(a)(3) of the Act.
The hearing concerns your application of [Title XVI AppDate], for
supplemental Security Income (SSI). I will consider whether you are disabled under section
1614(a)(3)(C) of the Social Security Act (the Act).
I will decide whether you continue to be disabled. To decide this issue, I will
determine whether you are disabled under section 1614(a)(3)(A) of the Social Security Act
(the Act).

Under the Act, I will find you disabled for those benefits or SSI
if you have a physical or mental condition(s) and: that:

 You are not working;


You have a condition(s) that causes marked and severe functional limitations; and



Your condition(s) has lasted 12 straight months, can be expected to last 12 straight
months, or can be expected to result in death.



Keeps you from doing any substantial gainful work; and



Has lasted 12 straight months, can be expected to last for 12 straight months, or can be
expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:


Any work you have done after your condition(s) began;



The severity of your condition(s); and



Whether your condition(s) meets or medically equals the requirements of a listed
impairment in Appendix 1 of Subpart P of our regulations or functionally equals the
listings.

 Whether you can do the kind of work , if any, you did in the past;
and


Whether you can do any other kind of work considering your age, education, and work
experience.

I will also consider whether you have enough earnings
under Social Security to be insured for a Period of Disability and Disability Insurance
Benefits. If you do, I must decide whether you became disabled while you were
insured.

Our records indicate that your date last insured is [CLMINFO.DLI]. If this is correct, I must
decide whether you became disabled on or before that date.

Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III, Part 404, Subpart B and Subpart P Part 416, Subpart I Part 404, Subpart B, Subpart P and Part 416, Subpart I .

The child should be present at this hearing so I can consider the case fully.

Issues I Will Consider
I will decide whether your disability has ended you continue to be disabled . To decide this issue, I will
apply the standard stated in section 223(f) 1614(a)(4) 223(f) and 1614(a)(4) of the Social Security Act. The ALJ
will consider:


Whether there has been any medical improvement relating to your ability to work
since we last found you disabled; and



Whether one of the exceptions to medical improvement stated in the Act and our
regulations applies.

In addition, if I decide that your disability ended, I will also determine whether you have
again become disabled since then.
Our regulations explain the rules for deciding whether you are still disabled and, if not, when
your disability ended. These rules are in the Code of Federal Regulations, Title 20, Chapter
III, Part 404, Subpart P. 416, Subpart I. 404, Subpart P and Part 416, Subpart I.

:
Issues I Will Consider

The general issues are whether you were overpaid benefits within the meaning of section
204/1631/204 and 1631 of the Social Security Act.

The specific issues are whether you were “without fault” as defined in
20 CFR § 404.507/416.552/404.507 and 416.552 in causing the overpayment and, if so,
whether recovery of the overpayment would (1) defeat the purpose of Title II/XVI/ II and
Title XVI of the Act, as defined in 20 CFR § 404.508/416.553/§ 404.508 and 416.553, or (2) be against equity and good conscience as defined in
20 CFR § 404.509/416.554/§ 404.509 and 416.554 . , or (3) impede efficient
or effective administration of Title XVI due to the small amount involved as defined in
20 CFR § 416.555.

The general issues are whether you were overpaid benefits within the meaning of section
204/1631/204 and 1631 of the Social Security Act and, if so, whether recovery of the
overpayment may be waived.
The specific issues are whether you were “without fault” as defined in
20 CFR § 404.507/416.552/§ 404.507 and 416.552 in causing the overpayment and, if so,
whether recovery of the overpayment would (1) defeat the purpose of Title II/ XVI/ II and
Title XVI of the Act, as defined in 20 CFR § 404.508/416.553/§ 404.508 and 416.553, or (2) be against equity and good conscience as defined in
20 CFR § 404.509/416.554/§ 404.509 and 416.554 . , or (3) impede efficient
or effective administration of Title XVI due to the small amount involved as defined in
20 CFR § 416.555.

The general issue is whether you are entitled to child's insurance benefits within the meaning
of section 202(d) of the Social Security Act.
The specific issues are whether you are dependent on the insured individual, or were
dependent on the insured individual at the time of his or her death; you are unmarried; and
whether the insured individual is fully insured, or was fully insured at the time of his or her
death.

The general issue is whether you are entitled to widower's benefits under section 202(f) of the
Social Security Act.
The specific issues are whether you are the widower's based on a relationship described under
20 CFR §§ 404.345. 404.346 of a person who was fully insured when he or she died; whether
the conditions under 20 CFR § 404.335 are met; whether you are at least 60 years old; and
whether you are unmarried.

The general issue is whether you are entitled to wife’s/divorced wife’s/husband’s/divorced
husband’s insurance benefits under section (202(c)) of the Social Security Act.
The specific issue is whether you were the legal wife/divorced wife/husband/divorced
husband of a fully insured wage earner. This will be determined by whether your relationship
was one described in 20 CFR §§ 404.345, 404.346, and whether one of the conditions set
forth under 20 CFR § 404.330 is met.

The general issue is whether you are eligible for supplemental security income under sections
1602 and 1611 of the Social Security Act. The specific issue is whether you have income or
resources in excess of the amount set by the regulations as the maximum allowable to be
eligible for supplemental security income.

The hearing concerns **[INSERT PERSONALIZED LANGUAGE NOTING ANY
APPLICATION(S) AND/OR THE PRINCIPAL ISSUES(S)]**.
**[INSERT PERSONALIZED LANGUAGE SPECIFYING THE ISSUES.]**
Our regulations explain the rules for deciding if you **[LANGUAGE DESCRIBING THE
PRINCIPAL ISSUE(S)]**. These rules appear in the Code of Federal Regulations,
**[SPECIFY TITLE(S), CHAPTER(S), PART(S) AND SUBPART(S)]**.

More About the Issues

[More Issues]

If I find that you have been disabled, I will also consider whether your disability continues
through the date of the decision or whether your condition(s) has improved.

If I find that you are disabled and that you have a substance use disorder (drug, alcohol, or
both), I also will decide whether it is a contributing factor material to the determination of
disability. This means I will decide whether you would be disabled if you were not using
drugs or alcohol. If drug addiction or alcoholism is a contributing factor material to the
determination of your disability, I will find you not disabled under Sections 223(d)(2), or
1614(a)(3), or 223(d)(2) and 1614(a)(3) of the Social Security Act.

More About the Issues

[More Issues]

If I find that you are disabled and that you have a substance use disorder (drug, alcohol, or
both), I also will decide whether it is a contributing factor material to the determination of
disability. This means I will decide whether you would be disabled if you were not using
drugs or alcohol. If drug addiction or alcoholism is a contributing factor material to the
determination of your disability, I will find you not disabled under Sections 223(d)(2), or
1614(a)(3), or 223(d)(2) and 1614(a)(3) of the Social Security Act.

Remarks
A vocational expert will testify at your hearing.
A vocational expert will appear at the hearing by video teleconference.
A vocational expert will appear at the hearing by telephone.
A medical expert will testify at your hearing.
A medical expert will appear at the hearing by video teleconference.
A medical expert will appear at the hearing by telephone.
A second medical expert will testify at your hearing.
A second medical expert will appear at the hearing by video
teleconference.
A second medical expert will appear at the hearing by telephone.
You will be able to see, hear, and speak to the experts using a color monitor.
You have a right to review the claim file. If you have not already
reviewed the file or arranged to do so, please call this office at the number shown at the top of
the first page of this notice.
**[PersonalizedRemarks]**

If You Disagree With the Issues
If you disagree with the issues or remarks listed above, you must tell me in writing why you
disagree. To prevent delays, you must tell me as soon as possible.
If You Have Objections
If you object to the issues or remarks listed above, you must tell me in writing why you
object. You must as soon as possible before the hearing, but not later than 5 business days
before the date of the hearing. You must state the reason(s) for your objection.

Your Right To Request a Subpoena

I may issue a subpoena that requires a person to submit documents or testify at your hearing. I
will do this if the person has evidence or information that you reasonably need to present your
case fully.
If you want me to issue a subpoena, you must write to me as soon as possible. I must receive
your request no later than 10 5 days before your hearing. In your
request, please tell me:


What documents you need and/or who the witnesses are;



The location of the documents or witnesses;



The important facts you expect the document or witness to prove; and



Why you cannot prove these facts without a subpoena.

What Happens At the Hearing?


I will ask you and any other witnesses to take an oath or to affirm that the testimony is
true.



You will have a chance to testify and tell me about your case.



You and your representative (if you have one) may submit documents,
present and question witnesses, state your case, and give written statements about the
facts and law.



I will ask you and any other witnesses questions that will help me make a decision in
your case.



We will make an audio recording of the hearing.

Travel Costs
We can pay certain travel costs when you, your representative, or needed witnesses must
travel more than 75 miles to the hearing. A sheet is enclosed to tell you about our rules for
paying travel costs. Please call this office if you want more information.

The Decision
After the hearing, I will issue a written decision and mail it to you. The decision will explain
the my findings of fact and conclusions of law. I will base my decision given all the evidence
of record, including the testimony at your hearing.

If You Have Any Questions
If you have any questions, please call, [Local Office Phone], or write this office. For your
convenience, our address is on the first page of this notice.

Sincerely,

[ALJ Name]
Administrative Law Judge

Enclosures: Possible ones listed below
Claimant
Form HA-L23 (Ban Reminder)
YRTR
HA-504
VHI
4631
4632
4633
VE Letter
ME1 Letter
ME2 Letter
Rep
Form HA-L23 (Ban Reminder)Notice Spanish
EDCP
HA-504 Spanish
HA-504
VHI Spanish
VHI
4631
4632
4633
VE Letter
ME1 Letter
ME2 Letter

BarCode Sheet
[If Rep present]
cc: [Rep Name]
[Rep Address]

When we can pay travel expenses
If you must travel more than 75 miles one way from your home or office to attend the hearing,
we can pay certain costs. Here are the rules that apply:


We can pay expenses such as the cost of a bus ticket or expenses for driving your car.



In certain circumstances, you may need meals, lodging, or taxicabs. The Administrative Law
Judge (ALJ) must approve these special travel costs before the hearing unless the costs
were unexpected and unavoidable.



The ALJ may also approve payment of travel expenses for your representative and any
witnesses he or she determines are needed at the hearing.



You must submit a written request for payment of travel expenses other than meals, lodging,
or taxicabs to the ALJ at the time of the hearing or as soon as possible after the hearing. List
what you spent and include supporting receipts. If you requested a change in the scheduled
location of the hearing to a location farther from your residence, we cannot pay you for any
additional travel expenses.



If you need money for travel costs in advance, you should tell the ALJ as soon as possible
before the hearing. We can make an advance payment only if you show that without it you
would not have the funds to travel to or from the hearing.



If you receive travel money in advance, you must give the ALJ an itemized list of your actual
travel costs and receipts within 20 days after your hearing.



If we gave you an advance payment that is more than the amount you are due for travel costs,
you must pay back the difference within 20 days after we tell you how much you owe us.



If we reimburse you for travel costs we follow the rules in the Code of Federal Regulations
and apply the same rates and conditions of payment that govern travel expenses for Federal
employees. 41 CFR Chapter 301 and 20 CFR 404.999a-999d/20 CFR 416.1495-1499/20
CFR 404.999a-999d, 416.1495-1499.