Last Update: 9/1/05 (Transmittal II-6-13)
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SOCIAL SECURITY ADMINISTRATION _____________________________________________________________ | |
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Refer to: TAHB [SSN] [XSSN] |
Office of Hearings and Appeals 5107 Leesburg Pike Falls Church, VA 22041-3255 Telephone: 703-605-8000 Date: [Month, Day, Year] | |
[Claimant's or Representative's First Name, Middle Initial and Last
Name]
[Address]
[City, State
Zip]
Dear [Mr./Ms.] [Addressee's Last Name]:
[“Re:” line below is generated only if notice is to representative.]
Re: [Claimant Name], [Claimant Address1], [Claimant Address2], [Claimant CSZ]
On [User keys in date], the Appeals Council denied a request for review of the Administrative Law Judge's [User chooses one: decision OR dismissal OR decision and dismissal]. The Post Office returned [that letter] OR [your copy of that letter] to the Council.
We are Giving You More Time to File a Civil Action
We are enclosing a copy of the original denial letter. However, the Appeals Council now extends the time within which you may file a civil action (ask for court review) for 60 days from the date you receive this letter. We assume that you received this letter 5 days after the date on it unless you show us that you did not receive it within that 5-day period.
We are enclosing a copy of the original denial letter.
If You Have Any Questions
If you have any questions, you may call, write or visit any Social Security office. If you do call or visit an office, please have this notice with you. The telephone number of the local office that serves your area is [FO Phone]. Its address is:
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[Field Office Address] |
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[Name] Administrative Appeals Judge OR Appeals Officer |
[“cc:” lines below are generated only if notice is to representative.]
cc:
[Claimant's Name]
[Claimant's Address]
[City, State Zip]