TN 4 (12-06)

A. When to use

Use the SSA-561-U2 (see GN 03102.250) for reconsideration under title II, title XVI, and for reconsideration for entitlement under title XVIII.

B. Procedure - How to complete SSA-561-U2

1. Initial determination

Before completing the form the FO should ensure that the issue being protested is an initial determination. If an initial determination was made, check the appropriate box and complete the form. If an initial determination has not been made, the SSA-561-U2 should not be completed. However, if the claimant/representative insists on completing the SSA-561-U2 even though an initial determination has not been made, check the “Claimant Insists on Filing” block and complete the form. See GN 03101.020.

2. Claimant SSN

Enter the Social Security number (SSN) of the claimant who is filing the appeal.

3. Claimant claim number

Enter the claim number (rather than SSN) in all Title II claims cases.

4. Supplemental Security Income (SSI) or Special Veterans Benefits (SVB) claim number

Enter the SSN of the individual who is filing for Title XVI or SVB.

If Title II is also involved, complete both the “Claimant Claim Number” block and the “SSI or SVB Claim Number” block.

5. Spouse's name and spouse's SSN

Enter the spouse's claim number in Title XVI cases in which the claimant and spouse are living together, regardless of whether the spouse is eligible or is a party to the appeal.

6. Claim for

Specify type of claim; e.g., RSI benefits, DI benefits, SSI payments, Special Veterans Benefits, HI/SMI entitlement, lump-sum death payment, disability freeze, deductions, earnings record revision.

NOTE: When reconsideration is requested on nonmedical concurrent Title II and Title XVI common issues, the request is deemed to apply to both claims, if the time limit for appealing either claim has not expired.

7. Reason for appeal

State why claimant believes determination is incorrect. In an overpayment case, clarify whether claimant is questioning the determination of overpayment or the waiver determination or both. Describe any additional evidence submitted. Document on RPOC if claimant refuses to give any information requested on the form.

8. Signature

Either the claimant or his/her representative may sign. A signature is not, however, required to process the reconsideration. If we have a written request that clearly shows dissatisfaction with an initial determination and it clearly originated with the claimant, process the reconsideration without the signature. (See GN 03102.100C.)

9. Timeliness of request

Check appropriate box. If request was not timely filed, attach claimant's explanation to the claims folder copy (see GN 03101.020).

10. RSI developmental requirements

Check the appropriate box to show the status and type of action taken. (See GN 03102.300 for developmental requirements.)

11. Social Security Office address

Show the FO address in all SSI cases. It is not necessary in reconsiderations involving other issues.

12. Routing instructions

Check the appropriate box, e.g., DDS, PSC, District Office, etc. (see GN 03102.175).

Reconsideration requests for nonmedical SSI-only cases remain in the FO.

13. Additional instructions

Record date appeal request received on the MCS appeals screens. For MCS exclusions, date stamp the receipt of the form.