Social Security Disability

Applicant Assistance Network



 


 
Case Profile Form Instructions
 

Please complete the case profile form below and submit.  Doing so will add your name to our case review system.  If the information you provide appears valid, we'll then add your name to our advocate referral list.  Please note that all required fields are marked with a red * star.  Failure to provide this information will automatically void your submission.  Once you have been added to our referral list, your case will be reviewed by one of our disability advocates who will determine if your case is viable.  If your case is found to have merit, you will be contacted for a phone interviewed.  Be prepared to provide additional information about your disorder.  This advocate contact and interview is free of charge.
 

Submit Once:

Please do not submit your profile more than once.  Submitting your profile more than once in a one year period, will decrease your chances of having your case reviewed.  Our database automatically removes duplicate profiles, so adding your information twice will delete your submission.  Please note that your profile may remain in our database for a period of up to one year or until it is chosen by an advocate for review.   The more information you provide, the better your chances of having your case reviewed.  Please be patient!  


 

 

Please complete the profile form and submit

Case Profile Form

First Name:*
Last Name:*
Address:*
City:*    State: *
Zip:*
 Phone:*
 E-mail:*                       
Gender:*  Male:      Female:    * Age:  
Highest level of education:*
Approx date disability began: *  Example: mm/dd/yy
List your impairments: Example:  Arthritis, heart disease, cancer, etc. 
 *1 . 

 2.  
Were you incarcerated at anytime
while suffering from your condition?		 Yes:      No:
 
Briefly describe how your*
 impairment (s) restrict your ability
 to perform work?
 
Do you use a prosthesis?* Yes:      No:
Do you have problems walking?* Yes:      No:
Do you have hand limitations?* Yes:      No:
Do you have problems sitting?* Yes:      No:
Previously applied for benefits?* Yes:      No:  
Date of previous decision?  Example: mm/dd/yy
Date case denied, if known?   Example: mm/dd/yy
Do you have a representative?* Yes:      No:
Last job title:*
Are your currently working?* Yes:      No:
Briefly describe the physical* 
 requirements of your current
 current job:
 
Date employment ended?   Example: mm/dd/yy
Average annual income                         $   Example: 19,000
Briefly describe your daily*
 activities:		  
Best time to contact you?*

  

 

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