Use this worksheet to fill in the official SSA form. Bluebook does not file with SSA — you must submit the official form yourself.
1. Claimant information
Full name
________________________
Social Security Number
XXX-XX-____ (write full SSN on official form)
Address
________________________
Phone
________________________
2. Claim dates
Application filed
__________
Denial letter dated
__________
Appeal deadline
__________
3. Reason for disagreement
Why do you disagree with SSA's decision? Be specific. What did they miss? What was wrong about their analysis?
4. New evidence
Any new medical records, test results, doctor opinions, or third-party statements that weren't in your original file? List them here. If new records exist, attach them or list provider + date so SSA can request them.
5. Representative
Lawyer, advocate, or family member assisting (optional). If you appoint a representative, file Form SSA-1696 to make it official.
Filing instructions
Take this worksheet plus the official SSA-561 (Request for Reconsideration) form and copy your answers onto the official form.
Sign and date the official form.
Submit by mail to your local SSA field office, in person, or online at ssa.gov.
Keep a copy of everything you send.
If your deadline is close, ask your field office to date-stamp your copy as proof of timely filing.
Generated by Bluebook to assist with SSA disability appeals. Not legal or medical advice. Not affiliated with the Social Security Administration. The official forms are at ssa.gov.