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For SSDI Benefits?

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Please fill out the following form as completely as possible in order to assist us in evaluating your disability case.

Contact Information

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Employment

*Are you working full time?
YesNo
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?
Are you working part time?*
If you are still working part time, please answer the following:

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Social Security

Have you applied for Social Security? *
YesNo
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?
YesNo
If you have applied, are you currently represented
by an attorney?
YesNo
Are you currently under the care of a doctor?*
YesNo
Please describe your disabilities and
why you feel you cannot work:

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