SUPPLEMENTARY INFORMATION FOR A REVIEW REQUEST / APPEAL

I refer to my [request for review / appeal] concerning the decision:
Benefit: [NAME OF THE BENEFIT]
Decision number: [NUMBER]
[Request for review / appeal] submitted: [DATE]

I submit the following supplementary information:

[EXPLAIN WHAT NEW INFORMATION OR EVIDENCE YOU WISH TO PRESENT AND HOW IT
AFFECTS YOUR CASE. E.g.:

I attach a new medical statement, which states that [WHAT].

OR: My situation has changed in that [EXPLAIN THE CHANGE].]

Attachments:
[LIST NEW ATTACHMENTS]

I request that this supplementary information be taken into account when
deciding the matter.

[DATE]
[FIRST NAME LAST NAME, PERSONAL IDENTITY CODE]