Form Ssa-3441-Bk - Disability Report - Appeal Page 3
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10Form Approved
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0144
DISABILITY REPORT – APPEAL
For SSA use only. Please do not write in this box.
Related SSN ___________________________
Number Holder ___________________________
If you are filling out this report for someone else, please provide information about him or her. When a question
refers to “you” or “your,” it refers to the person who is applying for disability benefits.
SECTION 1 – INFORMATION ABOUT THE DISABLED PERSON
1. A. Name (First, Middle, Last, Suffix)
1. B. Social Security Number
1. C. Daytime Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada)
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Check this box if you do not have a phone number where we can leave a message.
1. D. Alternate Phone Number – another number where we may reach you, if any
1. E. Email Address (Optional)
SECTION 2 – CONTACTS
Give the name of someone (other than your doctors) we can contact who knows about your medical conditions,
and can help you with your claim. (e.g., friend or relative)
2. A. Name (First, Middle, Last)
2. B. Relationship to Disabled Person
2. C. Mailing Address (Street or PO Box), include apartment number or unit if applicable.
City
State/Province
ZIP/Postal Code
Country (if not U.S.)
2. D. Daytime Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada)
2. E. Can this person speak and understand English?
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Yes
No
If no, what language does the contact person prefer?
2. F. Who is completing this form?
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The person who is applying for disability (Go to SECTION 3 - MEDICAL CONDITIONS).
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The person listed in 2.A. (Go to SECTION 3 - MEDICAL CONDITIONS).
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Someone else (Please complete the information below).
2. G. Name (First, Middle, Last)
2. H. Relationship to Disabled Person
2. I. Mailing Address (Street or PO Box) Include apartment number or unit if applicable.
City
State/Province
ZIP/Postal Code
Country (if not U.S.)
2. J. Daytime Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada)
Form SSA-3441-BK (03-2015) ef (03-2015)
Page 1
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