Name of Person Making Statement (If … information, put and request legally-binding digital signatures. It will be a long time before your hearing, so you will have plenty of time to keep sending them new information. When we make a decision on your claim, we send you a letter explaining our decision. After you receive a denial letter from the SSA giving the reason why you were denied, Form SSA-3441 is a crucial part of filing your appeal. If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. Date when you started participating in the plan or program: Use this space to provide any information you could not show in earlier sections of this form or any additional, information you feel we should know about. If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. give us on this report tells us where to request your medical and other records. and can help you with your claim. FormSSA-3441-BK (08-2010) ef(08-2010) SECTION 10 - REMARKS Use this section for any additional information you did not show in earlier parts of this form. Authorization to Disclose Information to the Social Security Administration, Request for Hearing by Administrative Law Judge, Your Right to Question The Decision Made On Your Claim, Your Right to Question A Decision Made On Your Supplemental Security Income (SSI) Claim, Your Right To Question The Decision To Stop Your Disability Benefits. Form Approved . Appeal forms are just a way to get the process started. Fillable Printable Form SSA-3881. Since you last told us about your education, If yes, what type? Form SSA-3441 | Disability Report - Appeal. Edit & Download Download . Get SSA-3441-BK 2018 Get form. B. Please note that the Disability Report - Appeal (form SSA-3441-BK) has replaced the old “Claimant’s Statement When Request for Hearing is Filed and the Issue is Disability.” To save files, right click and choose 'Save Target As' or 'Save Link As' File Attachment: Attachment Size; ssa_501_Request_for_ALJ_hearing.pdf: 84.55 KB : ssa-3441.pdf: 202.57 KB: 8145_ssa-827.pdf: 110.57 … Collection and Use of Personal Information, Sections 205 (42 U.S.C. 3. Form SSA-795 (09-2015) ef (09-2015) Destroy Prior Editions. Use the hints to be able to fill in the kind of career fields. Form SSA-3441 | Disability Report - Appeal. Social Security Search Menu Languages Sign in / up. Mailing Address (Street or PO Box) Include apartment number or unit if applicable. Many forms must be completed only by a Social Security Representative. Social Security Number . the instructions, gather the facts, and answer the questions. If you make an appointment with us, please complete as much of this report as you can. (Go to SECTION 3 - MEDICAL CONDITIONS). Include a ZIP or postal code with each address. such as a friend or family member. For SSA use only. However, failing to provide us with all or part of the information. 85 check-boxes. However, we may use it for the administration and integrity of Social Security programs. Download a copy of the form SSA-3441-BK here. The Social Security Administration (SSA) has a strict deadline for appeals. Check this box if you do not have a phone number where we can leave a message. What medical conditions were treated or evaluated? To facilitate statistical research, audit, or investigative activities necessary to ensure the, integrity of Social Security programs (e.g., to the U.S. Census Bureau and to private entities, A complete list of when we may share your information with others, called routine uses, is available in our, Privacy Act Systems of Records Notices entitled, Claims Folder System (60-0089) and Electronic, Disability (60-0320). TN 5 (06-20) DI 12095.030 SSA-3441-BK (Disability Report - Appeal) A. If you miss it, you might have to start over your application from the beginning. FORM SSA-3441-BK (1-2005) ef (12-2005) Use 2-2004 Edition Until Supply Is Exhausted PAGE 1 Approximate date the changes occurred: Month Day Year B. ssa 3441. We will use the form to update your disability information since you last completed a disability report. Can this person speak and understand English? If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. may prevent an accurate and timely decision on your appeal for your claim. Work from any gadget and share docs by email or fax. B. Information, from these matching programs can be used to establish or verify a person's eligibility for Federally funded, or administered benefit programs and for repayment of payments or delinquent debts under these, This information collection meets the requirements of 44 U.S.C. If you need more space, use SECTION 10 – REMARKS on the last page. Matching programs, compare our records with records kept by other Federal, State, or local government agencies. We will use the information you provide to update your disability appeal information. Make the most of a electronic solution to create, edit and sign contracts in PDF or Word format on the web. 423 (d)), and 1631 (42 U.S.C. Since you last told us about your medical conditions. First, you need to print Form SSA-3441 on the SSA’s website. When we make a decision on your claim, we send you a letter explaining our decision. 1. This page is for requesting a hearing. Show details. We will use the information. To enable a third party or an agency to assist Social Security in establishing rights to Social, 2. Form SSA-3441-BK (08-2010) ef (08-2010) Destroy Prior Editions SOCIAL SECURITY ADMINISTRATION DISABILITY REPORT - APPEAL Form Approved OMB No. (e.g., to the Government Accountability Office and Department of Veterans Affairs); 3. The person who is applying for disability (Go to SECTION 3 - MEDICAL CONDITIONS). 0960-0144 For SSA use only. Please be sure to include the number of the question you are answering, By logging in, you indicate that you have read and agree our, unless this report indicates otherwise. routine uses, which include but are not limited to the following: 1. On average this form takes 66 minutes to complete. Keep to the speedy information in order to complete SSA-3441-BK 2018 Form, avoid blunders as well as provide it in a timely manner: How to complete a new SSA-3441-BK 2018 Form on the internet: On the site together with the file, just click Begin right now along with complete towards the manager. If you do not wish to appeal online, you should submit: Form SSA-561, Request for Reconsideration, if you are requesting a reconsideration of your claim; OR. Form SSA-3441 is called the “Disability Report – Appeal.” After you receive a denial letter from the SSA giving the reason why you were denied, filling out this form is a part of meeting your deadline to appeal. an individual work plan with an employment network under the Ticket to Work Program? 0960-0144 PAGE 1 For SSA Use Only Do not write in this box. you provide to update your disability report information. Social Security Administration. Turn them into templates for numerous use, include fillable fields to gather recipients? Security at 1-800-772-1213 (TTY 1-800-325-0778). To make determinations for eligibility in similar health and income maintenance programs at the, 4.