Professional Affiliations

Name:
Address:
Phone:
E-mail:
What is the health condition preventing you from working (describe your main medical complaint first, and secondary problems as well.):
Have you been or will you be out of full-time work for over 12 months?
YesNo
Are you earning less than $1,000 a month?
YesNo
Have you worked and paid into the Social Security system for 5 of the last ten years?
YesNo
What is the status of your Social Security claim?
Have you filed an appeal (Request for Hearing)?
Was your appeal denied?
IMPORTANT NOTICE: Please be aware that we do not represent you until we have met with you, and both of us have agreed in writing that we will represent you. Meeting all deadlines will be your responsibility until that time. We do not give legal advice on this website, or agree to represent you as a result of your filling out this form.

I Agree & Understand