Social Security Questionnaire

Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Current Age*
Age
Phone Number*

Area CodePhone Number
Email Address*
example@example.com
How did you hear about us?*
Social Security Number
Are you married?*

YesNo
Name of Spouse

First NameLast Name
Do you have any minor children?*

YesNo
If so, how many?
Your Height & Weight

HeightWeight
What is the highest level of education you completed?*
Select one
What are your medical conditions?*
separate with commas or semicolons
List facilities where you get treatment, along with phone numbers
separate with commas or semicolons
Describe why you feel you are unable to work*
separate with commas or semicolons
Are you currently working?*

YesNo
If yes, what is your status?*

Full-timePart-time
What is your rate of pay?*
What is your current occupation?*
If not working, when you did you last work?*

MonthDayYear
Date
What was your primary occupation during the last 15 years?*
What was your last or most recent occupation?*
What was your rate of pay?*
How long did this job last?*
Why did you stop working?*
Have you tried vocational rehabilitation?

YesNo
Do you currently receive Social Security or SSI benefits?*

YesNo
If yes, then since when?

MonthDayYear
Date
Have you applied for Social Security benefits or SSI?*

YesNo
Is the claim currently pending?*

YesNo
Did you serve in the military?

YesNo
If yes, which branch of service?
Date Started Service

MonthDayYear
Date
Date Ended Service

MonthDayYear
Date
Type of Discharge
Have you ever filed a claim for compensation or pension benefits?

YesNo
What was the result?
What are your service connected conditions & their rating?
separate with commas or semicolons
Do you currently have a VA claim pending?

YesNo
Do you need assistance with your VA claim?

YesNo
Do you feel like you have recently been harassed by a company who was attempting to collect a debt from you?

YesNo
If you checked “Yes” above, you might be entitled to money damages for harassment and legal representation at no cost to you. We are affiliated with a consumer protection attorney who specializes in suing harassing bill collectors.
Would it be ok if he calls you to see if he can help you with that issue?

YesNo
Please verify that you are human*
Should be Empty: