I-2-7-96.Sample - Examination of Evidence

Last Update: 9/2/05 (Transmittal I-2-62)

EXAMINATION OF EVIDENCE

In the case of
_______________________________
(Claimant)

Claim for
______________________________
(Social Security Number)

_______________________________
(Wage Earner)

_______________________________
(Social Security Number)

DESCRIPTION OF ADDITIONAL EVIDENCE

(List Additional Evidence Here)

A. Claimant to check appropriate statements:

____

I examined the above listed evidence and have no comments to make.

____

I examined the above listed evidence and my comments are as follows: (Use reverse side if necessary.)

____

I have no further evidence to submit.

____

I am submitting the following evidence:


____

I do not wish to request a supplemental hearing to discuss this evidence.

____

I wish to request a supplemental hearing to discuss this evidence.

____

I do not wish to question, either orally or in writing, the author(s) of this (these) report(s).

____

I wish to question, either orally or in writing, the author(s) of this (these) report(s).

__________________

__________________

Security Employee)

(Date)

B. The claimant did not respond to our 10-day letter.

__________________

__________________

(Signature/Title of Social Security Employee

(Date)