Representation Form For Ssi/ssdb

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REPRESENTATION FORM FOR SSI/SSDB
PLEASE PRINT LEGIBLY
TODAY’S DATE
APPLICANT INFORMATION
Last Name
First Name
Middle Int.
Marital Status (Circle One)
Mr.
Miss
Single / Mar / Div / Sep / Wid
Mrs.
Ms.
Is this your legal name?
If not, what is your legal name?
(Former Name)
Birth Date
Age
Sex
______/______
M
F
Yes
No
Mo.
Yr.
Street Address
City
State
Zip Code
Home Phone No.
(
)
Please list all the services that you are currently receiving (Food Stamps, Medicaid, HEAP, etc.)
Are you currently on Public Assistance?
Yes
No
How were you referred to our website?
IF YOU ARE RECEIVING PUBLIC ASSISTANCE, INSTRUCT YOUR CASEWORKER TO COMPLETE AND FORWARD FORM #3879 TO LAD AS
SOON AS POSSIBLE.
What stage are you at in the disability process? (check one box)
Have applied
Have requested a Hearing
Received Initial/Recon Denial
Have received a Hearing Notice
Date of Hearing (if applicable)
Time of Hearing
Judge’s Name
Date of Denial (if any)
/
/
/
/
What is the cause of your disability?
The above information is true to the best of my knowledge. I also authorize SSI/SSD to release any information required
to process my form.
Submit by Email
B-5341 (07/09)

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