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Social Security Disability

Qualifying Questions

Name:			Home Phone:
Address:			Cell Phone:
City:			Other Phone:
State:			Email:
Zip:
Are You Currently Working? Yes No If yes, are you earning over $940 per month before taxes? Yes No   When did you last work? What was the longest job you had?  (Please include: How long you held it and the job title) What benefits are you applying for? SSI (Supplemental Security Income SSDI (Social Security Disability Insurance) What do you feel is your primary disabling health condition? Mental Physical Is there anything else you would like to tell me about your disabilities at this time? When did you apply for benefits? When was your appication denied? Did you appeal that decision? Yes No If yes, when? Did you receive a decision following that appeal? Yes No If yes, what was the date of that decision? What was the rationale offered by SSA for the decision? Did you file for a request for a hearing before an Administrative Law Judge? Yes No If yes, when did you appeal? Has a hearing been scheduled for that appeal? Yes No If yes, what date is it scheduled for?