I-4-1-93.Exhibit - Sample Certified Administrative Record

Last Update: 9/13/05 (Transmittal I-4-15)

Claimant

[Claimant Name]

Cross Ref Name

[Xname]

Account Number

[SSN]

Cross Ref Account No.

[XSSN]

 

[AMENDED] COURT TRANSCRIPT INDEX

PAGE NO.

Exhibits List (Index to Individual Exhibits)[1]

[User keys in page numbers]

Decision of Appeals Council, dated [User keys in date]

[User keys in page numbers]

Correspondence, dated [User keys in date]

[User keys in page numbers]

Action of Appeals Council on Request for Review, dated [User keys in date]

[User keys in page numbers]

Request for Review of Hearing Decision, dated [User keys in date]

[User keys in page numbers]

Hearing Decision, dated [User keys in date]

[User keys in page numbers]

Amended Notice of Hearing, dated [User keys in date]

[User keys in page numbers]

Appointment of Representative, dated [User keys in date]

[User keys in page numbers]

Notice of Hearing, dated [User keys in date]

[User keys in page numbers]

Acknowledgment of Request for Hearing, dated [User keys in date]

[User keys in page numbers]

Request for Hearing, dated [User keys in date]

[User keys in page numbers]

Transcript of Oral Hearing, dated [User keys in date]

[User keys in page numbers]

Order of Appeals Council Remanding Case to Administrative Law Judge, dated [User keys in date]

[User keys in page numbers]

Order of Appeals Council Receipt of Additional Evidence, dated [User keys in date]

[User keys in page numbers]

[User keys in any Other type of material], dated [User keys in date]

[User keys in page numbers]

Exhibits

[User keys in page numbers]

Appeals Council Letter Granting an Extension of Time, dated [User keys in date]

[User keys in page numbers]

Appeals Council Notice Declining Jurisdiction, dated [User keys in date]

[User keys in page numbers]

Statement of Exceptions, dated [User keys in date]

[User keys in page numbers]

Supplemental Notice of Hearing, dated [User keys in date]

[User keys in page numbers]

Notice Vacating Reconsideration Determination and Remanding to State Agency, dated [User keys in date]

[User keys in page numbers]


[1]  [User may make comments about any exhibit in a footnote (e.g., Exhibit 4 is missing).]