LISTING OF ALL FORMS USED IN A SOCIAL SECURITY DISABILITY CASE

FORMS UTILIZED ON SOCIAL SECURITY DISABILITY CASES

 

Case Information and Daily Activities Questionnaires

Daily Activities Questionnaire - a/k/a SSA 3733 - Adult Function Report

Daily Activities Questionnaire - a/k/a SSA 3380 - Adult Funtion Report - Third Party

Exertional Daily Activities Questionnaire

New Case Information Form

Pain Questionnaire

Pain Questionnaire (Tennessee Disability Determination Section version)

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Attorney's and Representative's Fees

Identifying Information for Possible Direct Payment of Authorized Fees (SSA-1695)

Petition to Obtain Approval of a Fee for Representing a Claimant Before the SSA (SSA-1560-U4)

Request for Appointed Representative's Direct Payment Information (SSA-1699)

Request for Business Entity Taxpayer Information (SSA-1694)

Sample Memorandum in Support of Motion for Attorney's Fees

Sample Written Fee Agreement (For Use in the Fee Agreement Process)

Service & Expense Agreement

Client Information and Representation

Appointment of Representative (SSA-1696-U6)

Sample Disability Interview Guide

Sample Instruction Sheet for New Clients

Disability Determination

Disability Report--Appeal (SSA-3441-BK)

Medical Source Statement of Ability to Do Work-Related Activities (Mental) (HA-1151-BK)

Medical Source Statement of Ability to Do Work-Related Activities (Physical) (HA-1151-BK)

Request for Review of Hearing Decision/Order (HA-520-U5)

Teacher Questionnaire (SSA-5665-BK)

Work Activity Report (Self-Employed Person) (SSA-820-F4)

Application for Disability Insurance Benefits (SSA-16-F6)

Authorization for Source to Release Information to the SSA (SSA-827)

Consent for Release of Information (SSA-3288)

Disability Report-Adult (SSA-3368-BK)

Disability Report-Child (SSA-3820-BK)

Medical Report on Adult with Allegation of HIV Infection (SSA-4814-F5)

Medical Report on Child with Allegation of HIV Infection (SSA-4815-F6)

Request for Hearing by Administrative Law Judge (HA-501-U5)

Request for Reconsideration (SSA-561-U2)

Residual Physical Functional Capacity Assessment (SSA-4734-U8)

Mental Residual Functional Capacity Assessment (SSA-4734-F4-SUP)

Sample Claimant/Physician Functional Capacity Report for HIV Condition

Statement of Claimant or Other Person (SSA-795)

Work History Report (SSA-3369-BK)

Entitlements/Retirement Benefits

Application for Retirement Insurance Benefits (SSA-1-BK)

Request for Social Security Earnings Information (SSA-7050-F4)

 

Family Relationships

Application for Wife's or Husband's Insurance Benefits (SSA-2-BK)

Certificate of Support (SSA-760-F4)

Statement Regarding Marriage (SSA-753)

Statement of Marital Relationship (SSA-754-F4)

 

Hearings and Post-Hearings (Disability Adjudication Process)

ALJ Bench Decision - Fully Favorable

Report of Continuing Disability Interview (SSA-454-BK)

Claimant's Medications (HA-4632)

Claimant's Medications (revised version without form number or date) (Revised version without form number or date.)

Claimant's Recent Medical Treatment (revised version without form number or date)

Claimant's Work Background (HA-4633)

Request for Withdrawal of Application (SSA-521)

Sample Brief to the Appeals Council on Procedural Errors of ALJ

Sample Hearing Questionnaire

Sample Hearing Summary

Sample Letter to Client After Receiving a Favorable Social Security Decision

Sample Pre-Hearing Letter to ALJ

Sample Pre-Hearing Summary for Advocate at Hearing

Statement by the Representative

Waiver of Written Notice of Hearing (HA-510)

Waiver of Your Right to Personal Appearance Before an Administrative Law Judge (HA-4608)

Judicial Review

Sample Complaint for Judicial Review

Sample Issues with Discussion for Inclusion in Complaint

 

Medical/Vocational Evidence

Employer Report of Special Wage Payments (SSA-131)

Psychiatric Review Technique (SSA-2506-BK)

Sample Checklist of Medical Impairment To Be Completed by Treating Physician

Sample Employer's Assessment of the Functional Requirements of Claimant's Post Relevant Work

Sample General Interrogatories to Physician

Sample Letter to Employer for Obtaining Evidence Relating to Claimant's Employment

Sample Objection to Consultative Evaluation Report for Failure to Perform Tests Under Listing

Sample Physician's Physical Capacities Evaluation, Quick Form

Sample Questions to Physician Formerly Used by the Administration to Gauge Work Capacity

Sample Report of Physician Setting Out Diagnosis, History, Treatment, Functional Limitation

Self-Employment/Corporate Office Questionnaire (SSA-4184)

 

Medicare

Claim for Amounts Due in the Case of a Deceased Beneficiary (SSA-1724)

Occupational Crosswalk for the Most Common Jobs

Call-Out Operator - 237.367-014

Cashier II - 211.462-010

Charge-Account Clerk - 205.367-014

Order Clerk - 249.362-026

Order Clerk, Food and Beverage - 209.567-014

Parking-Lot Attendant - 915.473-010

Photocopying-Machine Operator - 207.685-014

Storage-Facility Rental Clerk - 295.367-026

Surveillance-System Monitor - 379.367-010

 

Overpayments

Application to Proceed without Prepayment of Fees and Affidavit (AO 240)

Request for Waiver of Overpayment Recovery or Change in Repayment Rate (SSA-632-BK)

Sample Overpayment Questionnaire

 

Reopenings

Sample Brief of Claimant's Request for Reconsideration of Deadline Extension

 

Representative Payees

Request to Be Selected as Payee (SSA-11-BK)

 

Supplemental Security Income--Adult

Application for Supplemental Security Income (SSA-8000-BK)

Application for Supplemental Security Income (SSA-8001-BK)

Authorization for SSA to Obtain Account Records from Financial Institutions (SSA-4641-U2)

Claimant's Statement About Loan of Food or Shelter (SSA-5062)

Function Report - Adult (SSA-3373-BK)

Function Report - Adult - Third Party (SSA-3380-BK)

Living Arrangement/In-Kind Support and Maintenance Development Guide (SSA-8008)

Notice to Representative of Claimant Before the SSA (SSA-L1697-U3)

Request for Reconsideration--Disability Cessation (SSA-789-U4)

Sample Background Questionnaire for Determining Eligibility for Supp. Security Income

Statement for Determining Continuing Eligibility for Supp. Security Income Payments (SSA-8203-BK)

Statement of Income and Resources (SSA-8010-BK)

Statement of Living Arrangements, In-Kind Support and Maintenance (SSA-8006-F4)

 

Supplemental Security Income--Child

Childhood Disability Evaluation Form (SSA-538-F6)

Function Report-Child-Birth to 1st Birthday (SSA-3375-BK)

Function Report-Child-Age 1 to 3rd Birthday (SSA-3376-BK)

Function Report-Child-Age 3 to 6th Birthday (SSA-3377-BK)

Function Report-Child-Age 6 to 12th Birthday (SSA-3378-BK)

Function Report-Child-Age 12 to 18th Birthday (SSA-3379-BK)

Pain Report-Child (SSA-3371-BK)

Sample Questionnaires Seeking Functional Information About Childhood Disabilities

Sample School Activities Questionnaire

 

Survivor's Benefits

Claim for Amounts Due in the Case of a Deceased Beneficiary (SSA-1724)

Notice Regarding Substitution of Party Upon Death of Claimant (HA-539)

Reporting Changes That Affect Your Social Security Payment (SSA-1425)

 

Workers' Compensation Offset

Offset Worksheet--Disability Insurance Benefits (SSA-2455)

Request for Workers' Compensation/Public Disability Benefits Information (SSA-1709)

Sample Disbursal Sheet

Sample Social Security Disability Offset Worksheet

Statement Regarding Inferred Death--Continued and Unexplained Absence (SSA-723-F4)

Workers' Compensation/Public Disability Benefit Questionnaire (SSA-546) 

Client Information and Representation

Appointment of Representative (SSA-1696-U6)

Sample Disability Interview Guide

Sample Instruction Sheet for New Clients

Disability Determination

Disability Report--Appeal (SSA-3441-BK)

Medical Source Statement of Ability to Do Work-Related Activities (Mental) (HA-1151-BK)

Medical Source Statement of Ability to Do Work-Related Activities (Physical) (HA-1151-BK)

Request for Review of Hearing Decision/Order (HA-520-U5)

Teacher Questionnaire (SSA-5665-BK)

Work Activity Report (Self-Employed Person) (SSA-820-F4)

Application for Disability Insurance Benefits (SSA-16-F6)

Authorization for Source to Release Information to the SSA (SSA-827)

Consent for Release of Information (SSA-3288)

Disability Report-Adult (SSA-3368-BK)

Disability Report-Child (SSA-3820-BK)

Medical Report on Adult with Allegation of HIV Infection (SSA-4814-F5)

Medical Report on Child with Allegation of HIV Infection (SSA-4815-F6)

Request for Hearing by Administrative Law Judge (HA-501-U5)

Request for Reconsideration (SSA-561-U2)

Residual Physical Functional Capacity Assessment (SSA-4734-U8)

Mental Residual Functional Capacity Assessment (SSA-4734-F4-SUP)

Sample Claimant/Physician Functional Capacity Report for HIV Condition

Statement of Claimant or Other Person (SSA-795)

Work History Report (SSA-3369-BK)

Entitlements/Retirement Benefits

Application for Retirement Insurance Benefits (SSA-1-BK)

Request for Social Security Earnings Information (SSA-7050-F4)

Family Relationships

Application for Wife's or Husband's Insurance Benefits (SSA-2-BK)

Certificate of Support (SSA-760-F4)

Statement Regarding Marriage (SSA-753)

Statement of Marital Relationship (SSA-754-F4)

Hearings and Post-Hearings (Disability Adjudication Process)

ALJ Bench Decision - Fully Favorable

Report of Continuing Disability Interview (SSA-454-BK)

Claimant's Medications (HA-4632)

Claimant's Medications (revised version without form number or date) (Revised version without form number or date.)

Claimant's Recent Medical Treatment (revised version without form number or date)

Claimant's Work Background (HA-4633)

Request for Withdrawal of Application (SSA-521)

Sample Brief to the Appeals Council on Procedural Errors of ALJ

Sample Hearing Questionnaire

Sample Hearing Summary

Sample Letter to Client After Receiving a Favorable Social Security Decision

Sample Pre-Hearing Letter to ALJ

Sample Pre-Hearing Summary for Advocate at Hearing

Statement by the Representative

Waiver of Written Notice of Hearing (HA-510)

Waiver of Your Right to Personal Appearance Before an Administrative Law Judge (HA-4608)

Judicial Review

Sample Complaint for Judicial Review

Sample Issues with Discussion for Inclusion in Complaint

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