*Are you working full time? Yes No

If no, when did you stop working full time?

During the ten years before you stopped working, how many of those years were you employed? years

*Are you working part time? Yes No

If you are still working part time, please answer the following:
  hours per week you are working
$ gross earnings per week

*Have you applied for Social Security? Yes No

If your case has been denied, what is the date of the MOST RECENT denial notice?

Have you filed an appeal of this latest denial notice?
Yes No

If you have applied, are you currently represented
by an attorney? Yes No

*Are you currently under the care of a doctor? Yes No

Please describe your disabilities and
why you feel you cannot work: