United States of America Form Approved 

Railroad Retirement Board OMB No. 3220-0007

Form HA-1 (04-12) 

CLAIMANT APPEAL UNDER THE RAILROAD RETIREMENT ACT OR 

RAILROAD UNEMPLOYMENT INSURANCE ACT

IMPORTANT: Read the “Important Notice” on the 

next page and the accompanying Form 

HA-2 before completing this form.

RRB Claim Number 

Print Name (First, Middle Initial, Last) 

RETURN the completed form to: 

Bureau of Hearings and Appeals 

Railroad Retirement Board 

844 North Rush Street 

Chicago, Illinois 60611-2092

Print Address (Number, Street/Apt. No., Po Box) 

City State ZIP Code 

Telephone Number 

( )

Complete either Item A or B 3⁄4

 A. I hereby appeal the reconsideration decision reported in a 

letter dated __________________________________. 

 B. I hereby appeal the Hearings Officer’s decision reported in a 

letter dated __________________________________.

This appeal is based on what I believe to be mistakes of fact or errors of law. Details of these mistakes are as 

follows. 

(Attach additional sheets if necessary.) 

 I have no additional evidence.

 I intend to submit additional evidence as follows: 

I certify that the information I have provided is true to the best of my knowledge. I know that if I have made a 

false or fraudulent statement on this form or with any of the supporting evidence submitted, I am committing a 

crime which is punishable under Federal law by fine or imprisonment or both. 

IF CLAIMANT IS REPRESENTED Signature of Claimant

Name of Representative 

Address Date Signed 

If this appeal is filed by a person other than the 

claimant, state below the relationship to the claimant. 

(For example, Executor, Administrator, Guardian, etc.)

Telephone No. 

( ) ______________________________________ 

 Attorney  Non-Attorney
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES

Collection and Use of Information from Your Appeal Form

Under section 7(b)(6) of the Railroad Retirement Act of 1974 and section 5(b) of the Railroad 

Unemployment Insurance Act, the Railroad Retirement Board (RRB) is authorized to ask you for the 

information on this form. You are not required to provide us with this information, however, if you do not 

do so, we cannot process your appeal. 

Although the information which we request is almost never used for any purpose other than the 

processing of your appeal, the RRB does have the authority to release some or all of the following 

information to the indicated individuals, organizations, and/or agencies without your approval: 

1) Information may be released to an attorney, the Office of the President, a Congressional office, a 

labor union, or to the Department of State’s embassy or consular offices if they allege to be 

representing you at your request. 

2) Information may be released to other people who are receiving benefits based on the same railroad 

retirement account as you are, if the information affects their payments from the RRB. 

3) Information may be released to a person who will receive benefits on your behalf if the RRB 

decides that some medical condition keeps you from receiving your own benefits. 

4) Information (including medical records) may be released to people or organizations who are 

working for the RRB. 

5) Information may be released to your last employer to make sure that you are eligible to receive 

benefits under the Railroad Retirement Act or under the Railroad Unemployment Insurance Act. 

6) Information may be released in certain cases for law enforcement purposes and for court 

proceedings. 

A complete list of the persons, organizations or agencies to which the information you gave us may be 

released is published in the Federal Register. The current list is available in any office of the RRB, if 

you wish to see it. 

We estimate this form takes an average of 20 minutes per response, including the time needed for 

reviewing the instructions, getting the needed data, and reviewing the completed form. Federal agencies 

may not conduct or sponsor, and respondents are not required to respond to, a collection of information 

unless it displays a valid OMB number. If you wish, send comments regarding the accuracy of our 

estimate or any other aspect of this form, including suggestions for reducing the completion time, to: 

Chief of Information Resources Management, Railroad Retirement Board, 844 N. Rush Street, Chicago, 

IL 60611-2092. 

Form HA-1 (04-12) Page 2