Last Name

Address:

City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Phone:

Email:

Date of Birth:

Marital Status:

Single
Married
Divorced
Widowed

Are you filling out this form for someone else? If so, please enter:

Your Name:

Your Phone:

Claim Status:

Have not applied
Have applied but have not received a determination
Have applied and been denied
At original claim
At reconsideration
At hearing stage

How many times have you previously filed?

1
2
3
4
5 or more

If denied, what level?

Initial
Reconsideration
Administrative Law Judge
Appeals Council

Most recently denied January February March April May June July August September October November December 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Type of claim?

SSI
SSDI
I don't know

Date you became disabled: January February March April May June July August September October November December 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Have you worked 5 out of the last 10 years? yes no

Last date you worked? January February March April May June July August September October November December 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Are you working? yes no

Disability:

Physical/Mental Limitations: