Form SSA-3441-BK Disability Report-Appeal

APPEAL: The SSA-3441-BK (Disability Report-Appeal) is the form used to update disability information. It is used in conjunction with the SSA-561-U2 (Request for Reconsideration), SSA-789 (Request for Reconsideration-Disability Cessation), or HA-501 (Request for Hearing by Administrative Law Judge) when filing an appeal based on disability. Before determining whether you should complete this form, you need to refer to the SSA-561-U2, SSA-789, and HA-501 and determine whether one of those forms is the appropriate one to complete.

If you determine you need to complete an SSA-561-U2, SSA-789, or HA-501 and your disability claim was denied, or your disability benefits were stopped, because we determined you do not meet, or no longer meet, our disability requirements, you need to complete the SSA-3441-BK. If you are uncertain whether this is the appropriate form, review the letter you received. It will tell you why we denied your application or stopped your benefits.

If you are asked to complete form SSA-61, (Request For Review By A Federal Reviewing Official), it is available here.

EVIDENCE: When you file the appeal request, you should give us any evidence you have that shows why the determination we made was incorrect. This would include copies of any medical records you have that we did not consider in our previous determination.

You will also need to provide sufficient copies of the form SSA-827 (Authorization to Disclose Information to SSA). Count the number of sources you list in Section 3 on the SSA-3441-BK and add two extra copies.

If you have further questions about the form, or any other Social Security matter, you may call 1-800-772-1213 or contact your local Social Security office. If you are deaf or hard of hearing, call our toll-free “TTY” number, 1-800-325-0778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m. Please have available any letters you received from us.

You may complete Form SSA-3441-BK online;

OR

You may download Form SSA-3441-BK Disability Report-Appeal in Portable Document Format (PDF) .

The PDF permits you to print out a duplicate of the original form using ANY graphics printer. The PDF was developed by Adobe Systems, Inc. and allows the reader to print a publication close in appearance to the original printed version, preserving typography, columns, charts, tables and graphics. To read and print a PDF publication, you must have the Adobe Acrobat Reader software installed on your PC. Adobe Systems, Inc. permits the Social Security Administration and other organizations to offer this software to the public free of charge.

If you do not already have this special software, see our page on downloading and printing PDF documents. After you download the Adobe Acrobat Reader, come back to this page and download the PDF version of the SSA-3441-BK below. PDF files are printer independent and should print easily on any graphics printer (i.e., laser, inkjet, dot-matrix).

SSA-3441-BK in

Social Security Appeals Process

Forms:

• SSA-561-U2 , Request for Reconsideration
• SSA-789 (Request for Reconsideration-Disability Cessation)
• HA-501 (Request for Hearing by Administrative Law Judge)
• SSA-827, Authorization to Disclose Information to SSA