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(Take or mail the completed original to your local Social Security office, the Veterans Affairs Regional. Please complete the ALJ Hearing Request Form included with the reconsidered determination letter you received.A request for an ALJ hearing must be filed with OMHA within 60 days of receipt of the reconsideration decision. Complete this form and send it to the address for requesting a hearing (not the payment address) shown on your CDP notice. Include a copy of your CDP. Take the completed Proof of Personal Service form to the clerk's office (or e-file it, if available in your court) at least 5 court days before your hearing. Complete Form 4800-D to document all relevant information to be entered into the TIERS Fair Hearings and Appeals system. No. Yes (If Yes, have the representative complete and sign Section 3.) SECTION 3: AUTHORIZED HEARING REPRESENTATIVE INFORMATION. Enrollee Name, Enrollee Telephone Number, Enrollee Social Security Number. Instructions. This form may be used to request a hearing.