See if you are eligible for up to $3,600 per month.
We will review your evidence and predict your chances of being awarded benefits based on the data. The more information you provide, the better we can help you find out if you qualify. We will give a $50 grocery gift card to one applicant each week who completes the form and provides excellent answers to the work, health, and functioning questions.
Describe your medical condition that makes it hard to work.
*
Application Information
Name
*
*
Phone Number
*
Please enter a valid phone number.
Address
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Zip Code
*
Zip Code
Birthday
*
-
Month
-
Day
Year
Please enter your date of birth.
What is your sex?
*
Male
Female
What is the highest level of school you finished?
*
6th grade or less
7th to 11th grade
12th grade or more (including GED)
Are you currently earning more than $1,550 per month?
*
Yes
No
Social Security Number
*
Your signature provides your consent for your Advocate to review your personal information and access your medical and other records in order to process your claim.
Signature
*
Today's Date
*
-
Month
-
Day
Year
Please enter today's date.
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Work & Earnings
Social Security benefits are for those who have a severe health condition and cannot work full-time. To see if this program can help you, we need details about all the jobs you worked full-time for more than one month in the past five years. Be as detailed as if you were telling your best friend about your job, so they can understand what you do each day.
Where did you last work?
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What was your job title?
*
Describe a day in the life at your job.
*
When did you start working there?
*
-
Month
-
Day
Year
When did you stop working there?
*
-
Month
-
Day
Year
How much did you make each month?
*
Did you work any other full time jobs in the last five years for more than one month?
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Yes
No
Job 2: Who did you work for?
*
Job 2: What was your job title?
*
Job 2: Describe a day in the life at your job.
*
Job 2: When did you start working here?
*
-
Month
-
Day
Year
Date
Job 2: When did you stop working here?
*
-
Month
-
Day
Year
Date
Job 2: How much money did you make each month?
*
Did you work any other full time jobs in the last five years for more than one month?
*
Yes
No
Job 3: Who did you work for?
*
Job 3: What was your title?
*
Job 3: Describe a day in the life at your job?
*
Job 3: When did you start working here?
*
-
Month
-
Day
Year
Job 3: When did you stop working here?
*
-
Month
-
Day
Year
Job 3: How much money did you make each month?
*
Did you have any other jobs in the last 5 years?
*
Yes
No
Job 4: Who did you work for?
*
Job 4: What was your job title?
*
Job 4: Describe a day in the life at your job.
*
Job 4: When did you start working at this job?
*
-
Month
-
Day
Year
Date
Job 4: When did you stop working at this job?
*
-
Month
-
Day
Year
Date
Job 4: How much money did you make each month?
*
Your Health & Impact on Daily Living
Imagine you are speaking to a good friend who wants to understand how you are doing. Describe your health problems, how they affect your daily life, your routine, the difficulties you face, and what help you need.
*
If you had to help a friend rearrange houses for a full day, which option shows what you can do even with your health problems?
*
Lift a gallon of milk sometimes.
Lift a laptop sometimes and small bags of groceries often.
Lift a microwave sometimes and a large bag of cat litter often.
Lift a flat-screen TV sometimes and a heavy box of books often.
Lift a mini fridge sometimes and a large bag of dog food often.
(Optional) If you'd like, please tell us how your disability has impacted your everyday life.
Have you ever applied for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI)?
*
Please Select
I have not applied yet
I have applied but I am waiting for a decision
I have been denied recently
I am currently receiving social security disability
I am not sure
When did you apply last apply for benefits?
*
-
Month
-
Day
Year
Rough date is fine.
When was your application denied?
*
-
Month
-
Day
Year
Rough date is fine.
Why was your previous application denied?
*
Please Select
I was not medically disabled
I did not have enough work history / credits
I earned too much income
Other / Not Sure
Have you lived anywhere else since your condition began?
*
Yes
No
Please add the zip code of that other address.
Additional Zip Code
Have you lived at any other address since your condition began?
Yes
No
Please add the zip code of that other address.
Third Zip Code
How physical was your job?
Type a question
*
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