"You wouldn't believe how complicated the Social Security system is."

Art Stevens

            PERSONAL INFORMATION

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Your Name
Social Security Number
SSI or SSD
Address
City
State	ZIP
Home Phone
Work Phone
Fax (if available)
E-mail
Best Times To Contact You

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Have you filed for Social Security?	Yes No
Have you been denied?	Yes No
Did you request Reconsideration?	Yes No
Have you been denied on Reconsideration?	Yes No
If yes, what was the date of denial?
Have you requested a hearing?	Yes No
If yes, what is the date of your hearing?
What is the reason for your denial?
Disabilities include:
Are you currently working?	Yes No
What type of work have you done?
How long have you been unable to do any kind of work at all?
Are you currently be treated by a doctor?	Yes No
If yes, what is the doctor's name?
Has a doctor indicated that you are totally disabled from any kind of work?	Yes No

  

We will review your report and contact you as soon as possible.

Thank you !