Online Intake Form for Social Security Income Disability Case

Please fill out this form ONLY if you have a Social Security Income Disability Case for your child.

* Indicates required fields
* Child’s name:
   
* Parent/Guardian’s name:
   
* Address:
   
  Apt.:
   
* City:
   
* State:
   
* Zip Code:
   
* Home Phone:
   
Work Phone:
   
Cell Phone:
   
Email (if you have one):
   
* Child’s birthday:
   
* Total family income (yearly):
(You will be required to provide documentation of yearly income.)
   
* Child’s disability:
   
English?
   
Spanish only?
   
Other?
   
When did you receive initial denial?
   
Did you request an Administrative Law Judge (ALJ) Hearing?
   
  If so, when (date)?
   
  Did you file an appeal with the Appeals Council?
   
  If so, when (date)?
   
  Did you receive an Appeals Council decision?
   
  If so, when (date)?
   
  Did you file District Court action?
   
  If so, when (date)?
Security Code:(case sensitive)
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