• Social Security Disability New Client Intake Form

  • Please fill out this form in its entirety so that we can help you with your Social Security Disability claim.

    Please fill out this form in its entirety so that we can help you with your Social Security Disability claim.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     / /
  • Have you ever filed for Disability Benefits before?*
  • Do you agree to doing a phone hearing if your case gets to that stage?*
  • Maritial Status*
  • Do you have any children?*
  • Are any of them under the age of 18?
  • Format: (000) 000-0000.
  • When did you start working there?*
     / /
  • What was your last date worked?*
     / /
  • When did your condition get so bad that your earnings dropped below $1400 per month in gross income?*
     / /
  • Have you filed for early retirement benefits?
  • Do you have any resources over $2,000 if single or $3,000 if married? Bank accounts, retirement accounts, stock market or bond accounts, etc.
  • Have you ever filed for unemployment benefits?*
  • When?
     / /
  • Have you ever gotten workman's comp?*
  • When?
     / /
  • Have you ever had any alcohol or drug abuse?*
  • Have you ever served in the military?*
  • Have you or your spouse ever worked outside of the US?*
  • Have you or your spouse ever worked for the railroad for 5 years or more?*
  • Does a parent get half of their support from you?*
  • Format: (000) 000-0000.
  • Should be Empty: