Social Security Disability application Form

June 21, 2011

Social security disability application form can be filled out by a person having physical or mental disability and is unable to work. Below is a sample social security disability form, it might vary for different cases but more or less it is similar.
Sample social security disability application form

Personal Details:-

Social Security Number ______________________

First Name______________ Middle Name ____________ Last Name ___________

Residential Address    _______________________________

City__________________ State _________________ ZIP/Postal Code____________

Phone Number__________________________

Medical Condition:-

Date when your disability started_______________

Details about your physical and mental condition that limits your ability to work:

_____________________________________________________________

Details of medicine you take:

Name of the medicine               Consulted Doctor                Reason for your intake of medicine

__________________           _______________________    _____________________________

__________________           _______________________     _____________________________

__________________           ________________________   _____________________________

Name and Address of the health care provider _____________________________________________

Patient ID #______________________

Education and Job (if any):-

Name of the School _____________________________________

Address of the School ________________________________________

_________________________________________________________

Highest Grade Completed _____________________

Work History:

Date of last employment___________________________________

Describe the Job (mention the technical knowledge needed, use of equipment, duties performed):

_______________________________________________________________

Are you working now? ____(Y/N), If “Y” then which organization_______________________

Did you receive your salary when you were partially cured? _______(Y/N)

If “Y” then in what form? ______________

 

Download Social Security Disability application Form in Word Format

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