I-2-1-93.Sample - Exhibit List (Final) and Exhibit List - Second Hearing (Final)

Last Update: 9/28/05 (Transmittal I-2-67)

Exhibit 1 — First Request for Hearing

Claimant: John Doe SSN: 123-45-6789

Exh. No.

Part No.

Description

No. of Pages

 

 

PAYMENT DOCUMENTS/DECISIONS

 

1

A

Initial Disability Determination by State Agency, Title II, dated May 25, 1994 (with attached rationale)

4

2

A

Reconsideration Disability Determination by State Agency, Title II, dated November 22, 1994 (with attached rationale)

4

 

 

JURISDICTIONAL DOCUMENTS/NOTICES

 

1

B

Social Security Notice Dated May 25, 1994

3

2

B

Request for Reconsideration filed July 26, 1994

4

3

B

Social Security Notice of Reconsideration dated November 23, 1994

4

4

B

Request for Hearing filed December 20, 1994

2

 

 

NON-DISABILITY DEVELOPMENT

 

1

D

Leads/Protective Filing Worksheet dated January 2, 1994

2

2

D

Application for Disability Insurance Benefits filed January 31, 1994

4

3

D

Earnings record (dated/certified) February 5, 1994

4

 

 

DISABILITY RELATED DEVELOPMENT AND
DOCUMENTATION

 

1

E

Vocational Report dated February 8, 1994

6

2

E

Supplemental Questionnaire dated March 16, 1994

6

3

E

Reconsideration Disability Report dated June 30, 1994

5

4

E

Claimant's Statement When Request for Hearing is Filed and the Issue is Disability dated December 9, 1994

3

 

 

RECEIVED DURING HEARING

 

1

E

List of Claimant's Medications dated December 10, 1994

2

 

 

MEDICAL RECORDS

 

1

F

Medical records covering period from January 15, 1990 to June 30, 1994, from General Hospital

56

2

F

Psychiatric Review Technique Form by SA, dated May 25, 1994

 

3

F

Hospital Records for admission on March 17, 1994 through discharge on March 24, 1994, from General Hospital

7

4

F

Medical Report dated July 30, 1994, by Dr. C. M. Bones

3

5

F

Professional Qualifications, Dr. C. M. Bones

1

 

 

SUPPLEMENTAL SECURITY INCOME (SSI)

 

1

SSI

Record of SSI Inquiry dated January 2, 1994

1

2

SSI

Application for Supplemental Security Income Benefits filed January 31, 1994

6

3

SSI

Initial Disability Determination by State Agency, Title XVI, dated May 25, 1994 (with attached rationale)

4

4

SSI

Supplemental Security Income Notice dated May 25, 1994 (with attached rationale)

3

5

SSI

Reconsideration Disability Determination by State Agency, Title XVI, dated November 22, 1994 (with attached rationale)

4

6

SSI

Supplemental Security Income Notice of Reconsideration — Disability dated November 23, 1994

3

Exhibit 2—Subsequent Request for Hearing

Claimant: John Doe SSN: 123-45-6789

Exh. No

Part No.

Description

No. of Pages

 

 

PAYMENT DOCUMENTS/DECISIONS

 

B-1

A

ALJ's decision dated December 15, 1994, Notice of Decision, and list of exhibits marked #1 through #25.

11

B-2

A

Initial Disability Determination by State Agency, Title II, dated December 20, 1994 (with attached rationale)

4

B-3

A

Reconsideration Disability Determination by State Agency, Title II, dated January 5, 1995 (with attached rationale)

4

 

 

JURISDICTIONAL DOCUMENTS/NOTICES

 

B-1

B

Social Security Notice dated December 20, 1994

3

B-2

B

Request for Reconsideration filed December 22, 1994

4

B-3

B

Social Security Notice of Reconsideration dated January 5, 1994

4

B-4

B

Request for Hearing filed January 10, 1995

2

 

 

NON-DISABILITY DEVELOPMENT

 

B-1

E

Disability Report dated December 20, 1994

8

B-2

E

Vocational Report dated December 20, 1994

6

B-3

E

Supplemental Questionnaire dated December 21, 1994

6

B-4

E

Reconsideration Disability Report dated December 22, 1994

5

 

 

MEDICAL RECORDS

 

B-1

F

Hospital Records for admission on September 10, 1994 through discharge on November 15, 1994, from General Hospital

7

Exhibit 3 — Appeals Council or Court Remand Cases

Claimant: John Doe SSN: 123-45-6789

EXHIBITS ADMITTED IN CONNECTION WITH APPEALS COUNCIL REMAND

PAYMENT DOCUMENTS/DECISIONS

Exh. No.

Part. No.

Description

No. of Pages

3

A

Decision by ALJ issued on January 15, 1995

8

 

 

JURISDICTIONAL DOCUMENTS/NOTICES

 

5

B

Request for Review of Hearing Decision/Order filed January 17, 1995

2

6

A

Action of Appeals Council on Request for Review dated January 20, 1995

4

 

 

NON-DISABILITY DEVELOPMENT

 

DISABILITY RELATED DEVELOPMENT AND DOCUMENTATION

 

 

MEDICAL RECORDS

 

AC-1

F

Appeals Council Exhibit — Medical Report dated November 30, 1994, from Dr. C. M. Bones

2

AC-2

F

Appeals Council Exhibit — Medical Report dated December 5, 1995, from DR. C. M. Bones, Jr.

2

AC-3

F

Appeals Council Exhibit — Professional Qualifications of Dr. C. M. Bones, Jr.

1

5

F

Medical records covering period from January 15, 1994 to June 30, 1994, from General Hospital

36

6

F

Hospital Records for admission on March 17, 1994 discharge on March 24, 1994, from General Hospital

7

EXHIBITS ADMITTED AT SUPPLEMENTAL HEARING HELD ON JANUARY 27, 1995 FOLLOWING REMAND

7

F

Outpatient Medical Records covering period from November 15, 1994 to January 20, 1995, from General Hospital

8

ADDITIONAL CLAIM FILE, IF APPLICABLE:

Part (SSI) - Supplemental Security Income

Part (DWB) - Disabled Widow/Widower

Part (CDB) - Child's Disability Benefits