Sacramento Social Security Disability Case Evaluation Form

SOCIAL SECURITY DISABILITY CASE EVALUATION FORM
Sacramento Social Security, California Social Security Disability

Please fill out the following Case Evaluation form and provide as much information as possible. All information is kept strictly confidential and is used only by Anderson & Johnson for the evaluation of your case. By accepting and reviewing this completed form, we are not agreeing to represent you. Rather, we will evaluate your information to determine whether or not we can accept your case.

CONTACT INFORMATION

Your Name:

Street Address:

City/State/Zip:

Daytime Phone:

Email Address:

SSD CLAIM INFORMATION

Date of Birth

Educational Background:

Have you applied for disability?

What was the date of the last denial notice that you received?

When did your disability become so severe that you became unable to work?

What Type of work have you done over the past 15 years?

Why do you believe you are disabled and not able to work at any type of job?