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First Name* Last Name* Address City State Zip Phone* Alternate Phone Fax Email Address* Date of Birth 12345678910111213141516171819202122232425262728293031  Day JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember  Month 192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000  Year Are you currently working?  Yes  No   If you are not currently working, when did you stop working? Have you worked at least 5 of the last 10 years?  Yes  No   Have you filed a claim for Social Security Disability Benefits (SSD or SSI)?  Yes  No   What was the date that you filed your claim? If you have filed a claim, has your claim been denied?  Yes  No   If your claim was denied, what is the date of the most recent denial? What are the conditions, illnesses, or injuries that are preventing you from working? What are the medications that you are currently taking? Brief description of your disability issue:

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