*First Name:
*Last Name:
*Date of Birth: (mm/dd/yyyy)
Social Security #
*Telephone # (###-###-####)
Address:
City:
State:
Email:
First Name:
Last Name:
Program:
Email Address:
DSS Case Number:
District Office:
a. Do you have a current claim for Social Security Disability or SSI pending?
b. Do you have an attorney or representative assisting you with your application?
c. Are you currently working?*
d. Are you unable to work due to a medical or mental condition?*
e. Describe the condition(s) that keeps you from working.
f. Is anyone in your household, including children, disabled or receiving Special Education services?
g. Describe his/her condition.
h. List their name(s).
Check all that apply
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Do you know of someone or yourself who you feel may qualify for SSI/SSDI benefits and needs assistance with an application?
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