Appeal Of Determination Page 3
Download a blank fillable Appeal Of Determination in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Appeal Of Determination with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Signatures
I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true to the best of my knowledge. I understand that making
a false statement is a crime punishable under Federal law. By submitting this appeal, I am authorizing the
Social Security Administration to obtain and disclose information related to my income resources and
assets, foreign and domestic, consistent with applicable privacy laws. This information may include, but is
not limited to, information about my wages, account balances, investments, benefits, and pensions.
Please complete Section A. If you cannot sign, a representative may sign for you.
If someone assisted you,
complete Section B as well.
SECTION A
Your Signature:
Phone Number:
(
) ______ - ________
Your Home Street Address:
Apt. #:
City:
State:
ZIP Code:
Your Mailing Street Address (if different from home address):
Apt. #:
City:
State:
ZIP Code:
If you recently changed your address, put an X here:
If you would prefer that we contact someone else if we have additional questions, please provide the
person’s name and a daytime phone number.
Print First Name:
Print Last Name:
Phone Number:
( _____ ) ______ - ________
SECTION B
If someone assisted you, place an X in the box that describes that person and provide the rest of the
information requested below.
Other
Family Member
Attorney
Advocate
Specify:
Friend
Agency
Social Worker
Print First Name:
Print Last Name:
Phone Number:
( _____ ) ______ - ________
Address:
Apt. #:
City:
State:
ZIP Code:
Form SSA-1021 (07-2014)
Page 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Ssa-1021-inst - Instructions For Completing The Appeal Of Determination For Extra Help With Medicare Prescription Drug Plan Costs
Legal
Notice Of Exception To Administrative Law Judge's Determination Form - State Of New York Tax Appeals Tribunal
Legal
Related Categories
Parent category: Medical