Soar Data Form Muskegon County
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1
2Applicant ID # __ __ __ __ __
SOAR Data Form
Person Assisting Applicant
Name of Person Assisting Applicant: __________________________________________________________
Agency Name: ___________________________________________________________________________
City: ________________________________________
State: __________________________________
Phone Number: _______________________________
Email: __________________________________
Applicant
First Name__________________________________
Last Name_______________________________
Date of Birth _________________________ (mm/dd/yyyy) SS#_____________________________________
Gender:
Female
Male
Veteran:
Yes
No
Don’t Know
Housing Status:
Homeless*
At risk of homelessness
Housed
* SOAR defines homelessness as living on the street, in shelters, doubled up or in less than permanent housing
Length of Time Homeless (as of protective filing date):
_____ OR
______ OR
_____
[Estimates are acceptable]
Years
Months
Days
Was this person receiving any state, county or other public assistance
(cash, check or medical insurance) prior to applying for SSI/SSDI?
Yes
No
If 'Yes', what type of public assistance?
Application Status (Please check one)
New SOAR application (Complete section A only)
SOAR-initiated reconsideration or appeal (Complete section B only)
Application not initiated using SOAR (Complete section C only)
A: New SOAR Application
1.
Protective filing date (consent form faxed to SSA)
___ / ___ / ____
(mm/dd/yyyy)
2.
Application date (application packet submitted to SSA):
___ / ___ / ____
(mm/dd/yyyy)
3.
Completed and submitted SSA 1696 Appointment of Representative form?
Yes
No
4.
Were medical records collected and submitted?
Yes
No
5.
Was a medical summary report written and submitted?
Yes
No
6.
Was report co-signed by physician or psychologist?
Yes
No
7.
Was quality review of application done prior to submission?
Yes
No
8.
Was a Consultative Exam (CE) ordered?
Yes
No
9.
Date of decision
___ / ___ / ____
(mm/dd/yyyy)
10. Outcome of decision
Approved
Denied
11. Approved for SSI?
Yes
No
12. Approved for SSDI?
Yes
No
13. Representative payee needed?
Yes
No
M171 Rev. 3/01/10
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