Lyle M. Clark, Jr., Attorney at Law

 

(425) 452 3092

 

 

 

 

   

SSDI / SSI Evaluation Form


Please fill in all fields

Name *
First

Last
Address *
Street Address

City

State

Zip Code

Country
Phone *
  -     -  
Email *
Date of Birth *

MM
  /  
DD
  /  
YYYY
Type of Claim *
 Disability Insurance Benefits (SSDI)
 Disabled Child’s Benefits under a parent’s account (SSDI)
 Disabled Widow’s Benefits (SSDI)
 Supplemental Security Income (SSI)
 Both SSDI and SSI
Claim History *
 I have not yet filed a claim
 My application was initially denied
 My request for reconsideration was denied
 I have requested a hearing
 I have a hearing scheduled
 I received an unfavorable hearing decision
 I have been receiving benefits but SSA is now trying to terminate me
 I have received a notice that I was overpaid
Please enter date of last
denial or hearing *
What medical condition(s)
do you have that prevent
you from working? *
Date Last Worked *

MM
  /  
DD
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YYYY
Job Title or Description *
 

SSI / SSDI

 

Wills / Trusts / Probate

 

Family Law

 

Divorce

 

Evaluation Form

 

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Lyle M. Clark, Jr., Attorney at Law   |   40 Lake Bellevue, Suite 100   |   Bellevue WA 98005   |   View Map   |   lyle@lmclarkattorney.com

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