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Federal Benefits Advisory Group - Social Security Disability Advocates

FREE CASE EVALUATION

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FREE CASE EVALUATION

UPON RECEIPT OF THE COMPLETED FORM WE WILL PROVIDE YOU WITH A CASE EVALUATION. Only provide identifying data that you feel comfortable with, however, Age, Past Work, Date of Disability and detailed list of medical conditions will enhance the evaluation to include such regulations as the appropriate Medical/Vocational Guidelines and Listing of Impairments that may apply.







DATE
Full Name (First, M.I, Last):
Date of Birth:
Address:
City:
State (for Puerto Rico, Select PR):
E-mail Address:
Are you working:
Date you last worked:
When did you become disabled? (Onset Date):
Have you applied for Social Security disability?:
If Yes, when did you apply?:
At what stage is your claim?:
Please give us a detailed description
  


THANK YOU FOR THIS OPPORTUNITY TO ASSIST YOU IN THIS MATTER