TN 3 (12-03)

Identifying data (complete all applicable items):

1. N/H Name:                    SSN:                 

2. Appellant Name (if different):                          

3. Cross reference SSN/BOAN (if any):                

4. Type of Case (circle one):  Hearing   AC Review   Civil Action

5. Hearing Request Date:                 

6. Date HA-501 (HO copy) forwarded to ODAR:                

7. Type of Folder(s) Needed (check all applicable):

   ( ) SSI Aged

   ( ) SSI Blind/Disabled

   • ( ) current folder ( ) prior folder

   ( ) T2 DI B

   • ( )current folder ( ) prior folder

   ( ) DWB

   ( ) RSI

8. ( ) Other       

   Query Information(show pertinent information and attach copies):

   1. PCACS date:                shows:                

   2. SSI2 date:                shows:                

   3. HA04 date:                shows:                

   4. Other type:                 date:          shows:                

   Field Office Actions

   1. Component contacted:                

   2. Date of initial request:                

   3. Date of followup request:                

   4. Office making referral:                

   5. Office contact person:                

   6. Office telephone number:                

   7. Date referred to ORC: