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You may contact us at 731-336-2686 or e-mail us at
services@ssaadvocates.org
before you proceed any further with the forms on this page. All forms
are provided by double clicking the links below. The forms within this
web site are used for the purpose of securing Social Security disability
representation. |
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SSA- Form
3369 Instructions |
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Please print the form entitled " Form
3369 Work History Report".
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Please read and complete all requested
information.
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This form is required by the SSA and is a
good way for us to get an accurate account of your work history. If
you have a copy of the form that you provided to the SSA, just enclose
it along with the other completed forms.
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SSA- Form
1696 Instructions |
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Print the SSA Form 1696. You must print
the 4 identical forms labeled “Appointment of Representative”.
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Please complete the following information
on each form: name, social security number, complete mailing address,
phone number, date, and your signature.
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This form is provided by the SSA and they
have provided instructions for completing this documentation titled
“Information for Claimants”. To acknowledge your choice of
REPRESENTATION, SSA requires this information.
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Fee Agreement
Form Instructions |
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Print the form titled “Fee Agreement”.
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Please read the document and complete the
following information: print name, signature, date, complete mailing
address, contact phone numbers, and emergency contact information.
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SSA uses this form to determine our fees.
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Medical
Release Form Instructions |
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Print the form titled “Medical Release”
form.
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Please read the document and complete the
following information.
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Print name, Social Security number, date
of birth, and address.
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The facility section will be completed
later as additional medical evidence is developed.
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Complete each form with your original signature, please be as detailed
as possible and mail ALL documents to my address below. Keep a copy for
yourself. We will need an opportunity to speak with you and learn more
about your claim before actual representation occurs. |
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