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First Name:     M.I.:   

Last Name:  

Address: 

City: 

State:     Zip: 

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1.  List your social security number.   

2. Have you applied for social security disability?  Yes  No
If yes, has your claim been denied?  Yes  No
If your claim has been denied, list the date on the Denial Notice letter you received.   / /                           

3. Did you have a hearing before an Administrative Law Judge?
 Yes  No
If you have had a hearing, have you received a decision?
 Yes  No 
If you have received a decision, list the date of the judge's decision.
 / /    

4.  Your current age.  

5.  List the highest grade of school you completed.
Eighth Grade or LessTwelfth GradeSelect OneSome College or post-high school trainingCollege Graduate 

6.  List the date you were last regularly employed.  / /    

7. List the types of work you have performed on a regular basis over the last 15 years.
 

8.  Describe all of your disabilities and why they keep you from working.