Last Update: 9/1/05 (Transmittal II-6-13)
SOCIAL SECURITY ADMINISTRATION
OFFICE OF HEARINGS AND APPEALS
ORDER OF APPEALS COUNCIL
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In the case of |
Claim for |
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______________________________ |
______________________________ |
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(Claimant) |
|
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______________________________ |
______________________________ |
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(Wage Earner) (Leave blank if same as above) |
(Social Security Number) |
The Appeals Council has received additional evidence which it is making part of the record. That evidence consists of the following exhibits:
Exhibit AC-1
Exhibit AC-2
Exhibit AC-3
[Add more exhibits as necessary]
Date:
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______________________________ |
______________________________ |
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Claimant |
Social Security Number |
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______________________________ |
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|
Wage Earner |
AC EXHIBITS LIST
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EXHIBIT NO. |
DESCRIPTION |
NO. OF PAGES |
COURT |
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Exhibit AC-1 |
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Exhibit AC-2 |
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Exhibit AC-3 |
[Add more exhibits as necessary]