1. Individual's Information

*First Name:

A value is required.

*Last Name:

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*Date of Birth: (mm/dd/yyyy)

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Social Security #

*Telephone #

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Address:

City:

State:

Email:

2. Assigned Social Worker:   (If Applicable)

First Name:

Last Name:

Address:

City:

State:

 

Program:

Email Address:

DSS Case Number:

District Office:

3. Individual Detail:

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).

 

4. Language:

Check all that apply

Does anyone in your household speak

English

Spanish

Other Please Specify:

 

 
 

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