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Parsons Technology resource data  |  1995-07-01  |  96.8 KB  |  857 lines
  1. PARSONS TECHNOLOGY RESOURCE FILE
  2. D035xx01
  3. D035xx02
  4. D035xx03
  5. D035xx04
  6. D035xx05
  7. D035xx06
  8. D035xx07
  9. D035xx08
  10. D035xx09
  11. D035xx10y
  12. SSAPPI  
  13. SSAPPI00
  14. SSAPPI01
  15. SSAPPI02)
  16. SSAPPI03
  17. SSAPPI04
  18. SSAPPI05
  19. SSAPPI06
  20. SSAPPI07C
  21. SSAPPI08
  22. SSAPPI09
  23. SSAPPI10
  24. SSAPPI11
  25. SSAPPI12
  26. DISABILITY BENEFITS
  27. In making an application to obtain Social Security disability
  28. benefits, certain documents are necessary.  This checklist will be
  29. printed for your use in preparing to apply for Social Security
  30. disability benefits.
  31.  Social Security number
  32.  Proof of age
  33.  Social Security number of any dependents claiming benefits
  34.  Proof of age for any dependents claiming benefits
  35.  Copy of your W-2 (Wage and Tax Statement); or if you are
  36. self-employed, your Federal tax
  37. return for the past year
  38.  Marriage certificate if applying for spouse's benefits
  39.  Personal check, bank statement or other banking document if you
  40. want your check directly
  41. deposited to your account
  42. The following information may be required by the Social Security
  43. office if you apply for disability benefits.  Do not wait to apply if
  44. you do not have all the information.  The SSA office can help you
  45. obtain the additional information needed.
  46. Describe the type of injury or illness:
  47. BFREE6
  48. Describe how the injury or illness prevents you from working:
  49. BFREE6
  50. Date you stopped working:
  51. Have you returned to work?
  52. If you returned to work:
  53. Employer's name:
  54. Employer's address:
  55. Employer's address:
  56. Employer's city:
  57. State:
  58. Employer's zip:
  59. Date returned to work:
  60. Description of job duties:
  61. BFREE6
  62. Complete the following information for as many doctors, hospitals and
  63. clinics that have treated you for the disability:
  64. HOSPITAL(S):
  65. 1.  Hospital or Clinic:
  66. Name of treating physician:
  67. Address:
  68. Address:
  69. City:
  70. State :
  71. Zip Code:
  72. Telephone Number:
  73. Hospital/Clinic and/or Medicaid number:
  74. TREATMENT INFORMATION:
  75. Date of treatment:
  76. Type of treatment/tests:
  77. BFREE6
  78. PRESCRIPTIONS:
  79. 1. Name of prescription:
  80. Dosage:
  81. 2. Name of prescription:
  82. Dosage:
  83. 3. Name of prescription:
  84. Dosage:
  85. 4. Name of prescription:
  86. Dosage:
  87. 5. Name of prescription:
  88. Dosage:
  89. RESTRICTIONS:
  90. Restrictions doctor placed on you:
  91. BFREE6
  92. 2.  Hospital or Clinic:
  93. Name of treating physician:
  94. Address:
  95. Address:
  96. City:
  97. State :
  98. Zip Code:
  99. Telephone Number:
  100. Hospital/Clinic and/or Medicaid number:
  101. TREATMENT INFORMATION:
  102. Date of treatment:
  103. Type of treatment/tests:
  104. BFREE6
  105. PRESCRIPTIONS:
  106. 1. Name of prescription:
  107. Dosage:
  108. 2. Name of prescription:
  109. Dosage:
  110. 3. Name of prescription:
  111. Dosage:
  112. 4. Name of prescription:
  113. Dosage:
  114. 5. Name of prescription:
  115. Dosage:
  116. RESTRICTIONS:
  117. Restrictions doctor placed on you:
  118. BFREE6
  119. 3.  Hospital or Clinic:
  120. Name of treating physician:
  121. Address:
  122. Address:
  123. City:
  124. State :
  125. Zip Code:
  126. Telephone Number:
  127. Hospital/Clinic and/or Medicaid number:
  128. TREATMENT INFORMATION:
  129. Date of treatment:
  130. Type of treatment/tests:
  131. BFREE6
  132. PRESCRIPTIONS:
  133. 1. Name of prescription:
  134. Dosage:
  135. 2. Name of prescription:
  136. Dosage:
  137. 3. Name of prescription:
  138. Dosage:
  139. 4. Name of prescription:
  140. Dosage:
  141. 5. Name of prescription:
  142. Dosage:
  143. RESTRICTIONS:
  144. Restrictions doctor placed on you:
  145. BFREE6
  146. 4.  Hospital or Clinic:
  147. Name of treating physician:
  148. Address:
  149. Address:
  150. City:
  151. State :
  152. Zip Code:
  153. Telephone Number:
  154. Hospital/Clinic and/or Medicaid number:
  155. TREATMENT INFORMATION:
  156. Date of treatment:
  157. Type of treatment/tests:
  158. BFREE6
  159. PRESCRIPTIONS:
  160. 1. Name of prescription:
  161. Dosage:
  162. 2. Name of prescription:
  163. Dosage:
  164. 3. Name of prescription:
  165. Dosage:
  166. 4. Name of prescription:
  167. Dosage:
  168. 5. Name of prescription:
  169. Dosage:
  170. RESTRICTIONS:
  171. Restrictions doctor placed on you:
  172. BFREE6
  173. 5.  Hospital or Clinic:
  174. Name of treating physician:
  175. Address:
  176. Address:
  177. City:
  178. State :
  179. Zip Code:
  180. Telephone Number:
  181. Hospital/Clinic and/or Medicaid number:
  182. TREATMENT INFORMATION:
  183. Date of treatment:
  184. Type of treatment/tests:
  185. BFREE6
  186. PRESCRIPTIONS:
  187. 1. Name of prescription:
  188. Dosage:
  189. 2. Name of prescription:
  190. Dosage:
  191. 3. Name of prescription:
  192. Dosage:
  193. 4. Name of prescription:
  194. Dosage:
  195. 5. Name of prescription:
  196. Dosage:
  197. RESTRICTIONS:
  198. Restrictions doctor placed on you:
  199. BFREE6
  200. 6.  Hospital or Clinic:
  201. Name of treating physician:
  202. Address:
  203. Address:
  204. City:
  205. State :
  206. Zip Code:
  207. Telephone Number:
  208. Hospital/Clinic and/or Medicaid number:
  209. TREATMENT INFORMATION:
  210. Date of treatment:
  211. Type of treatment/tests:
  212. BFREE6
  213. PRESCRIPTIONS:
  214. 1. Name of prescription:
  215. Dosage:
  216. 2. Name of prescription:
  217. Dosage:
  218. 3. Name of prescription:
  219. Dosage:
  220. 4. Name of prescription:
  221. Dosage:
  222. 5. Name of prescription:
  223. Dosage:
  224. RESTRICTIONS:
  225. Restrictions doctor placed on you:
  226. BFREE6
  227. 7.  Hospital or Clinic:
  228. Name of treating physician:
  229. Address:
  230. Address:
  231. City:
  232. State :
  233. Zip Code:
  234. Telephone Number:
  235. Hospital/Clinic and/or Medicaid number:
  236. TREATMENT INFORMATION:
  237. Date of treatment:
  238. Type of treatment/tests:
  239. BFREE6
  240. PRESCRIPTIONS:
  241. 1. Name of prescription:
  242. Dosage:
  243. 2. Name of prescription:
  244. Dosage:
  245. 3. Name of prescription:
  246. Dosage:
  247. 4. Name of prescription:
  248. Dosage:
  249. 5. Name of prescription:
  250. Dosage:
  251. RESTRICTIONS:
  252. Restrictions doctor placed on you:
  253. BFREE6
  254. 8.  Hospital or Clinic:
  255. Name of treating physician:
  256. Address:
  257. Address:
  258. City:
  259. State :
  260. Zip Code:
  261. Telephone Number:
  262. Hospital/Clinic and/or Medicaid number:
  263. TREATMENT INFORMATION:
  264. Date of treatment:
  265. Type of treatment/tests:
  266. BFREE6
  267. PRESCRIPTIONS:
  268. 1. Name of prescription:
  269. Dosage:
  270. 2. Name of prescription:
  271. Dosage:
  272. 3. Name of prescription:
  273. Dosage:
  274. 4. Name of prescription:
  275. Dosage:
  276. 5. Name of prescription:
  277. Dosage:
  278. RESTRICTIONS:
  279. Restrictions doctor placed on you:
  280. BFREE6
  281. 9.  Hospital or Clinic:
  282. Name of treating physician:
  283. Address:
  284. Address:
  285. City:
  286. State :
  287. Zip Code:
  288. Telephone Number:
  289. Hospital/Clinic and/or Medicaid number:
  290. TREATMENT INFORMATION:
  291. Date of treatment:
  292. Type of treatment/tests:
  293. BFREE6
  294. PRESCRIPTIONS:
  295. 1. Name of prescription:
  296. Dosage:
  297. 2. Name of prescription:
  298. Dosage:
  299. 3. Name of prescription:
  300. Dosage:
  301. 4. Name of prescription:
  302. Dosage:
  303. 5. Name of prescription:
  304. Dosage:
  305. RESTRICTIONS:
  306. Restrictions doctor placed on you:
  307. BFREE6
  308. 10.  Hospital or Clinic:
  309. Name of treating physician:
  310. Address:
  311. Address:
  312. City:
  313. State :
  314. Zip Code:
  315. Telephone Number:
  316. Hospital/Clinic and/or Medicaid number:
  317. TREATMENT INFORMATION:
  318. Date of treatment:
  319. Type of treatment/tests:
  320. BFREE6
  321. PRESCRIPTIONS:
  322. 1. Name of prescription:
  323. Dosage:
  324. 2. Name of prescription:
  325. Dosage:
  326. 3. Name of prescription:
  327. Dosage:
  328. 4. Name of prescription:
  329. Dosage:
  330. 5. Name of prescription:
  331. Dosage:
  332. RESTRICTIONS:
  333. Restrictions doctor placed on you:
  334. BFREE6
  335. 11.  Hospital or Clinic:
  336. Name of treating physician:
  337. Address:
  338. Address:
  339. City:
  340. State :
  341. Zip Code:
  342. Telephone Number:
  343. Hospital/Clinic and/or Medicaid number:
  344. TREATMENT INFORMATION:
  345. Date of treatment:
  346. Type of treatment/tests:
  347. BFREE6
  348. PRESCRIPTIONS:
  349. 1. Name of prescription:
  350. Dosage:
  351. 2. Name of prescription:
  352. Dosage:
  353. 3. Name of prescription:
  354. Dosage:
  355. 4. Name of prescription:
  356. Dosage:
  357. 5. Name of prescription:
  358. Dosage:
  359. RESTRICTIONS:
  360. Restrictions doctor placed on you:
  361. BFREE6
  362. 12.  Hospital or Clinic:
  363. Name of treating physician:
  364. Address:
  365. Address:
  366. City:
  367. State :
  368. Zip Code:
  369. Telephone Number:
  370. Hospital/Clinic and/or Medicaid number:
  371. TREATMENT INFORMATION:
  372. Date of treatment:
  373. Type of treatment/tests:
  374. BFREE6
  375. PRESCRIPTIONS:
  376. 1. Name of prescription:
  377. Dosage:
  378. 2. Name of prescription:
  379. Dosage:
  380. 3. Name of prescription:
  381. Dosage:
  382. 4. Name of prescription:
  383. Dosage:
  384. 5. Name of prescription:
  385. Dosage:
  386. RESTRICTIONS:
  387. Restrictions doctor placed on you:
  388. BFREE6
  389. 13.  Hospital or Clinic:
  390. Name of treating physician:
  391. Address:
  392. Address:
  393. City:
  394. State :
  395. Zip Code:
  396. Telephone Number:
  397. Hospital/Clinic and/or Medicaid number:
  398. TREATMENT INFORMATION:
  399. Date of treatment:
  400. Type of treatment/tests:
  401. BFREE6
  402. PRESCRIPTIONS:
  403. 1. Name of prescription:
  404. Dosage:
  405. 2. Name of prescription:
  406. Dosage:
  407. 3. Name of prescription:
  408. Dosage:
  409. 4. Name of prescription:
  410. Dosage:
  411. 5. Name of prescription:
  412. Dosage:
  413. RESTRICTIONS:
  414. Restrictions doctor placed on you:
  415. BFREE6
  416. 14.  Hospital or Clinic:
  417. Name of treating physician:
  418. Address:
  419. Address:
  420. City:
  421. State :
  422. Zip Code:
  423. Telephone Number:
  424. Hospital/Clinic and/or Medicaid number:
  425. TREATMENT INFORMATION:
  426. Date of treatment:
  427. Type of treatment/tests:
  428. BFREE6
  429. PRESCRIPTIONS:
  430. 1. Name of prescription:
  431. Dosage:
  432. 2. Name of prescription:
  433. Dosage:
  434. 3. Name of prescription:
  435. Dosage:
  436. 4. Name of prescription:
  437. Dosage:
  438. 5. Name of prescription:
  439. Dosage:
  440. RESTRICTIONS:
  441. Restrictions doctor placed on you:
  442. BFREE6
  443. 15.  Hospital or Clinic:
  444. Name of treating physician:
  445. Address:
  446. Address:
  447. City:
  448. State :
  449. Zip Code:
  450. Telephone Number:
  451. Hospital/Clinic and/or Medicaid number:
  452. TREATMENT INFORMATION:
  453. Date of treatment:
  454. Type of treatment/tests:
  455. BFREE6
  456. PRESCRIPTIONS:
  457. 1. Name of prescription:
  458. Dosage:
  459. 2. Name of prescription:
  460. Dosage:
  461. 3. Name of prescription:
  462. Dosage:
  463. 4. Name of prescription:
  464. Dosage:
  465. 5. Name of prescription:
  466. Dosage:
  467. RESTRICTIONS:
  468. Restrictions doctor placed on you:
  469. BFREE6
  470. 16.  Hospital or Clinic:
  471. Name of treating physician:
  472. Address:
  473. Address:
  474. City:
  475. State :
  476. Zip Code:
  477. Telephone Number:
  478. Hospital/Clinic and/or Medicaid number:
  479. TREATMENT INFORMATION:
  480. Date of treatment:
  481. Type of treatment/tests:
  482. BFREE6
  483. PRESCRIPTIONS:
  484. 1. Name of prescription:
  485. Dosage:
  486. 2. Name of prescription:
  487. Dosage:
  488. 3. Name of prescription:
  489. Dosage:
  490. 4. Name of prescription:
  491. Dosage:
  492. 5. Name of prescription:
  493. Dosage:
  494. RESTRICTIONS:
  495. Restrictions doctor placed on you:
  496. BFREE6
  497. 17.  Hospital or Clinic:
  498. Name of treating physician:
  499. Address:
  500. Address:
  501. City:
  502. State :
  503. Zip Code:
  504. Telephone Number:
  505. Hospital/Clinic and/or Medicaid number:
  506. TREATMENT INFORMATION:
  507. Date of treatment:
  508. Type of treatment/tests:
  509. BFREE6
  510. PRESCRIPTIONS:
  511. 1. Name of prescription:
  512. Dosage:
  513. 2. Name of prescription:
  514. Dosage:
  515. 3. Name of prescription:
  516. Dosage:
  517. 4. Name of prescription:
  518. Dosage:
  519. 5. Name of prescription:
  520. Dosage:
  521. RESTRICTIONS:
  522. Restrictions doctor placed on you:
  523. BFREE6
  524. 18.  Hospital or Clinic:
  525. Name of treating physician:
  526. Address:
  527. Address:
  528. City:
  529. State :
  530. Zip Code:
  531. Telephone Number:
  532. Hospital/Clinic and/or Medicaid number:
  533. TREATMENT INFORMATION:
  534. Date of treatment:
  535. Type of treatment/tests:
  536. BFREE6
  537. PRESCRIPTIONS:
  538. 1. Name of prescription:
  539. Dosage:
  540. 2. Name of prescription:
  541. Dosage:
  542. 3. Name of prescription:
  543. Dosage:
  544. 4. Name of prescription:
  545. Dosage:
  546. 5. Name of prescription:
  547. Dosage:
  548. RESTRICTIONS:
  549. Restrictions doctor placed on you:
  550. BFREE6
  551. 19.  Hospital or Clinic:
  552. Name of treating physician:
  553. Address:
  554. Address:
  555. City:
  556. State :
  557. Zip Code:
  558. Telephone Number:
  559. Hospital/Clinic and/or Medicaid number:
  560. TREATMENT INFORMATION:
  561. Date of treatment:
  562. Type of treatment/tests:
  563. BFREE6
  564. PRESCRIPTIONS:
  565. 1. Name of prescription:
  566. Dosage:
  567. 2. Name of prescription:
  568. Dosage:
  569. 3. Name of prescription:
  570. Dosage:
  571. 4. Name of prescription:
  572. Dosage:
  573. 5. Name of prescription:
  574. Dosage:
  575. RESTRICTIONS:
  576. Restrictions doctor placed on you:
  577. BFREE6
  578. 20.  Hospital or Clinic:
  579. Name of treating physician:
  580. Address:
  581. Address:
  582. City:
  583. State :
  584. Zip Code:
  585. Telephone Number:
  586. Hospital/Clinic and/or Medicaid number:
  587. TREATMENT INFORMATION:
  588. Date of treatment:
  589. Type of treatment/tests:
  590. BFREE6
  591. PRESCRIPTIONS:
  592. 1. Name of prescription:
  593. Dosage:
  594. 2. Name of prescription:
  595. Dosage:
  596. 3. Name of prescription:
  597. Dosage:
  598. 4. Name of prescription:
  599. Dosage:
  600. 5. Name of prescription:
  601. Dosage:
  602. RESTRICTIONS:
  603. Restrictions doctor placed on you:
  604. BFREE6
  605. EMPLOYER(S):
  606. 1.  Name of employer:
  607. Address:
  608. Address:
  609. City:
  610. State:
  611. Zip Code:
  612. Beginning date:
  613. Ending date:
  614. Type of work performed:
  615. BFREE6
  616. 2.  Name of employer:
  617. Address:
  618. Address:
  619. City:
  620. State:
  621. Zip Code:
  622. Beginning date:
  623. Ending date:
  624. Type of work performed:
  625. BFREE6
  626. 3.  Name of employer:
  627. Address:
  628. Address:
  629. City:
  630. State:
  631. Zip Code:
  632. Beginning date:
  633. Ending date:
  634. Type of work performed:
  635. BFREE6
  636. 4.  Name of employer:
  637. Address:
  638. Address:
  639. City:
  640. State:
  641. Zip Code:
  642. Beginning date:
  643. Ending date:
  644. Type of work performed:
  645. BFREE6
  646. 5.  Name of employer:
  647. Address:
  648. Address:
  649. City:
  650. State:
  651. Zip Code:
  652. Beginning date:
  653. Ending date:
  654. Type of work performed:
  655. BFREE6
  656. 6.  Name of employer:
  657. Address:
  658. Address:
  659. City:
  660. State:
  661. Zip Code:
  662. Beginning date:
  663. Ending date:
  664. Type of work performed:
  665. BFREE6
  666. 7.  Name of employer:
  667. Address:
  668. Address:
  669. City:
  670. State:
  671. Zip Code:
  672. Beginning date:
  673. Ending date:
  674. Type of work performed:
  675. BFREE6
  676. 8.  Name of employer:
  677. Address:
  678. Address:
  679. City:
  680. State:
  681. Zip Code:
  682. Beginning date:
  683. Ending date:
  684. Type of work performed:
  685. BFREE6
  686. 9.  Name of employer:
  687. Address:
  688. Address:
  689. City:
  690. State:
  691. Zip Code:
  692. Beginning date:
  693. Ending date:
  694. Type of work performed:
  695. BFREE6
  696. 10.  Name of employer:
  697. Address:
  698. Address:
  699. City:
  700. State:
  701. Zip Code:
  702. Beginning date:
  703. Ending date:
  704. Type of work performed:
  705. BFREE6
  706. 11.  Name of employer:
  707. Address:
  708. Address:
  709. City:
  710. State:
  711. Zip Code:
  712. Beginning date:
  713. Ending date:
  714. Type of work performed:
  715. BFREE6
  716. 12.  Name of employer:
  717. Address:
  718. Address:
  719. City:
  720. State:
  721. Zip Code:
  722. Beginning date:
  723. Ending date:
  724. Type of work performed:
  725. BFREE6
  726. 13.  Name of employer:
  727. Address:
  728. Address:
  729. City:
  730. State:
  731. Zip Code:
  732. Beginning date:
  733. Ending date:
  734. Type of work performed:
  735. BFREE6
  736. 14.  Name of employer:
  737. Address:
  738. Address:
  739. City:
  740. State:
  741. Zip Code:
  742. Beginning date:
  743. Ending date:
  744. Type of work performed:
  745. BFREE6
  746. 15.  Name of employer:
  747. Address:
  748. Address:
  749. City:
  750. State:
  751. Zip Code:
  752. Beginning date:
  753. Ending date:
  754. Type of work performed:
  755. BFREE6
  756. 16.  Name of employer:
  757. Address:
  758. Address:
  759. City:
  760. State:
  761. Zip Code:
  762. Beginning date:
  763. Ending date:
  764. Type of work performed:
  765. BFREE6
  766. 17.  Name of employer:
  767. Address:
  768. Address:
  769. City:
  770. State:
  771. Zip Code:
  772. Beginning date:
  773. Ending date:
  774. Type of work performed:
  775. BFREE6
  776. 18.  Name of employer:
  777. Address:
  778. Address:
  779. City:
  780. State:
  781. Zip Code:
  782. Beginning date:
  783. Ending date:
  784. Type of work performed:
  785. BFREE6
  786. 19.  Name of employer:
  787. Address:
  788. Address:
  789. City:
  790. State:
  791. Zip Code:
  792. Beginning date:
  793. Ending date:
  794. Type of work performed:
  795. BFREE6
  796. 20.  Name of employer:
  797. Address:
  798. Address:
  799. City:
  800. State:
  801. Zip Code:
  802. Beginning date:
  803. Ending date:
  804. Type of work performed:
  805. BFREE6
  806. RETIREMENT BENEFITS
  807. Depending on your situation, you may need some or all of the following
  808. in making an application to obtain Social Security retirement
  809. benefits.  This checklist will be printed for your use in preparing to
  810. apply for Social Security retirement benefits.
  811.  Social Security number
  812.  Birth Certificate
  813.  Your W-2 forms or your complete tax return (including Schedule
  814. SE) for the most recent year
  815.  Your spouse's birth certificate and Social Security number, if
  816. your spouse is also applying for
  817. benefits
  818.  Children's birth certificates and Social Security numbers, if
  819. applying for children's benefits
  820.  Checking or savings account information if you want your benefits
  821. directly deposited to your
  822. checking or savings account
  823.  Any other Social Security number under which you or your
  824. dependents have received Social Security
  825. payments
  826. SSAPPI01 Benefits
  827. This required section askswhat benefit information isneeded and provides achecklist in order to applyfor Social Security disabilitybenefits or retirementbenefits.  Press [Ctrl+F1] formore information.
  828.     REQUIRED TRANSFER SECTIONCount  Field
  829.     REQUIRED BENEFITS SECTION    (SECTION 1 OF 1) [NOTE: To apply for Social Security benefits a special form is required  that can only be obtained from your local Social Security office or by  calling a toll-free number: 1-(800)-772-1213.  The following will give  you a checklist of items needed to apply for Social Security benefits.     Select the desired benefits information:           Disability           Retirement]
  830. This required section requests the type of benefit informationthat is needed (Disability or Retirement).Enter an X to prepare an information list for a Social SecurityDISABILITY application.  The program will generate a checklist ofitems you need when applying for Social Security disabilitybenefits.  Access the Expert Guide for more information.Enter an X to prepare an information list for a Social SecurityRETIREMENT application.  The program will generate a checklist ofitems you need when applying for Social Security retirementbenefits.  Access the Expert Guide for more information.
  831.     CONTINUATION OF BENEFITS SECTION - DISABILITY    (SECTION 1 OF 1)                            DISABILITY BENEFITS     In making an application to obtain Social Security disability     benefits, certain documents are necessary.  This checklist will be     printed for your use in preparing to apply for Social Security     disability benefits.        * Social Security number        * Proof of age        * Social Security number of any dependents claiming benefits        * Proof of age for any dependents claiming benefits        * Copy of your W-2 (Wage and Tax Statement); or if you are          self-employed, your Federal tax return for the past year        * Marriage certificate if applying for spouse's benefits        * Personal check, bank statement or other banking document if you          want your check directly deposited to your account
  832. This required section serves as a checklist of what is needed inorder to apply for Social Security disability benefits.
  833.     CONTINUATION OF BENEFITS SECTION - DESCRIPTION OF INJURY OR ILLNESS    (SECTION 1 OF 1)     The following information may be required by the Social Security     office if you apply for disability benefits.  Do not wait to apply if     you do not have all the information.  The SSA office can help you     obtain the additional information needed.     Describe the type of injury or illness:     Describe how the injury or illness prevents you from working:     Date you stopped working:     Have you returned to work?      Yes       No     If you returned to work:     Employer's name:     Employer's address:     Employer's address:     Employer's city:     State:     Employer's zip:     Date returned to work:     Description of job duties:
  834. This required section gives a description of the type of injury orillness, how this is preventing you from work or whether you havereturned to work.Describe the injury or illness which interferes with your ability todo any kind of work for which you are suited for at least a year.Access the Expert Guide for more information.Describe how the injury or illness interferes with your ability todo any kind of work for which you are suited for at least a year.Using the format MM/DD/YYYY, enter the date that you stopped workingbecause of injury or illness.Enter an X if you have returned to work since you were injured orbecame ill.Enter an X if you have NOT returned to work since you were injuredor became ill.Enter your employer's name.Enter your employer's street address.Enter your employer's extended street address.Enter the city in which your employer is located.Enter the state in which your employer is located.  Press [F8] toselect a state from the selection box.Enter your employer's zip code.Using the format MM/DD/YYYY, enter the date you returned to work.If you have returned to work, describe the nature of your jobduties.  You may want to describe how your job duties have changedsince your injury or illness.
  835.     (    (    D    R    R    n    |    |    
  836.     CONTINUATION OF BENEFITS SECTION - HOSPITALS    (SECTION 1 OF 1)     Complete the following information for as many doctors, hospitals and     clinics that have treated you for the disability:     HOSPITALS: 1.  Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State :     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 2.  Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 3.  Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 4.  Hospital or Clinic:     Name of treating     physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 5.  Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     Do you need additional space?        Yes       No
  837. This required section gives the name(s) of the hospital(s) orclinic(s).  Also included is information about your physician,treatment, and restrictions.Enter the name of the hospital or clinic that has treated you foryour injury or illness.Enter the name of the physician treating you for your injury orillness.Enter the street address of the hospital or clinic.Enter the extended street address of the hospital or clinic.Enter the city in which the hospital or clinic is located.Enter the state/province in which the hospital or clinic is located.Press [F8] to select a state from the selection box.Enter the hospital or clinic's zip/postal code.Enter the phone number of the hospital or clinic, including the areacode.  Enter numbers only.Enter the hospital or clinic number, if known, or your Medicaidnumber, if applicable.Using the format MM/DD/YYYY, enter the date of treatment.Describe the type of treatment or the tests administered.Enter the name of the prescription.  This information may beobtained from the label affixed to the prescription.Enter the prescription dosage.  This information may be obtainedfrom the label affixed to the prescription.Describe any restrictions that the doctor placed on you (forexample, restrictions which prohibit or limit your ability to workor perform daily activities).Enter an X to enter additional hospital and treatment information.Enter an X if you do NOT need to enter additional hospital andtreatment information.
  838.          .    .    J    X    X    t    
  839.     CONTINUATION OF BENEFITS SECTION - HOSPITALS    (SECTION 1 OF 1)     Complete the following information for as many doctors, hospitals and     clinics that have treated you for the disability:     HOSPITALS: 6.  Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State :     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 7.  Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 8.  Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 9.  Hospital or Clinic:     Name of treating     physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 10. Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     Do you need additional space?        Yes       No
  840. This required section gives the name(s) of the hospital(s) orclinic(s).  Also included is information about your physician,treatment, and restrictions.Enter the name of the hospital or clinic that has treated you foryour injury or illness.Enter the name of the physician treating you for your injury orillness.Enter the street address of the hospital or clinic.Enter the extended street address of the hospital or clinic.Enter the city in which the hospital or clinic is located.Enter the state/province in which the hospital or clinic is located.Press [F8] to select a state from the selection box.Enter the hospital or clinic's zip/postal code.Enter the phone number of the hospital or clinic, including the areacode.  Enter numbers only.Enter the hospital or clinic number, if known, or your Medicaidnumber, if applicable.Using the format MM/DD/YYYY, enter the date of treatment.Describe the type of treatment or the tests administered.Enter the name of the prescription.  This information may beobtained from the label affixed to the prescription.Enter the prescription dosage.  This information may be obtainedfrom the label affixed to the prescription.Describe any restrictions that the doctor placed on you (forexample, restrictions which prohibit or limit your ability to workor perform daily activities).Enter an X to enter additional hospital and treatment information.Enter an X if you do NOT need to enter additional hospital andtreatment information.
  841.          .    .    J    X    X    t    
  842.     CONTINUATION OF BENEFITS SECTION - HOSPITALS    (SECTION 1 OF 1)     Complete the following information for as many doctors, hospitals and     clinics that have treated you for the disability:     HOSPITALS: 11. Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State :     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 12. Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 13. Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 14. Hospital or Clinic:     Name of treating     physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 15. Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     Do you need additional space?        Yes       No
  843. This required section gives the name(s) of the hospital(s) orclinic(s).  Also included is information about your physician,treatment, and restrictions.Enter the name of the hospital or clinic that has treated you foryour injury or illness.Enter the name of the physician treating you for your injury orillness.Enter the street address of the hospital or clinic.Enter the extended street address of the hospital or clinic.Enter the city in which the hospital or clinic is located.Enter the state/province in which the hospital or clinic is located.Press [F8] to select a state from the selection box.Enter the hospital or clinic's zip/postal code.Enter the phone number of the hospital or clinic, including the areacode.  Enter numbers only.Enter the hospital or clinic number, if known, or your Medicaidnumber, if applicable.Using the format MM/DD/YYYY, enter the date of treatment.Describe the type of treatment or the tests administered.Enter the name of the prescription.  This information may beobtained from the label affixed to the prescription.Enter the prescription dosage.  This information may be obtainedfrom the label affixed to the prescription.Describe any restrictions that the doctor placed on you (forexample, restrictions which prohibit or limit your ability to workor perform daily activities).Enter an X to enter additional hospital and treatment information.Enter an X if you do NOT need to enter additional hospital andtreatment information.
  844.     (    (    D    R    R    n    |    |    
  845.     CONTINUATION OF BENEFITS SECTION - HOSPITALS    (SECTION 1 OF 1)     Complete the following information for as many doctors, hospitals and     clinics that have treated you for the disability:     HOSPITALS: 16. Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State :     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 17. Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 18. Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 19. Hospital or Clinic:     Name of treating     physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:     HOSPITALS: 20. Hospital or Clinic:     Name of treating physician (optional):     Address:     Address:     City:     State:     Zip Code:     Telephone Number:     Hospital/Clinic and/or Medicaid number:     TREATMENT INFORMATION:     Date of treatment:     Type of treatment/tests:     PRESCRIPTIONS:     1 Name of prescription:       Dosage:     2 Name of prescription:       Dosage:     3 Name of prescription:       Dosage:     4 Name of prescription:       Dosage:     5 Name of prescription:       Dosage:     RESTRICTIONS:     Restrictions doctor placed on you:
  846. This required section gives the name(s) of the hospital(s) orclinic(s).  Also included is information about your physician,treatment, and restrictions.Enter the name of the hospital or clinic that has treated you foryour injury or illness.Enter the name of the physician treating you for your injury orillness.Enter the street address of the hospital or clinic.Enter the extended street address of the hospital or clinic.Enter the city in which the hospital or clinic is located.Enter the state/province in which the hospital or clinic is located.Press [F8] to select a state from the selection box.Enter the hospital or clinic's zip/postal code.Enter the phone number of the hospital or clinic, including the areacode.  Enter numbers only.Enter the hospital or clinic number, if known, or your Medicaidnumber, if applicable.Using the format MM/DD/YYYY, enter the date of treatment.Describe the type of treatment or the tests administered.Enter the name of the prescription.  This information may beobtained from the label affixed to the prescription.Enter the prescription dosage.  This information may be obtainedfrom the label affixed to the prescription.Describe any restrictions that the doctor placed on you (forexample, restrictions which prohibit or limit your ability to workor perform daily activities).
  847.     CONTINUATION OF BENEFITS SECTION - EMPLOYMENT INFORMATION    (SECTION 1 OF 1) 1.  Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed: 2.  Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed: 3.  Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed: 4.  Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed: 5.  Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed:     Do you need additional space?       Yes       No
  848. This required section allows you to include employment information.Enter an X if you want to complete screens regarding your employmenthistory.  Generally, Social Security will require your workexperience for each employer during the past fifteen years.Enter the most recent employer's name.Enter the employer's street address.Enter the employer's extended street address.Enter the city in which your employer is located.Enter the state/province in which the employer is located.  Press[F8] to select a state from the selection box.Enter your employer's zip/postal code.Using the format MM/DD/YYYY, enter the date you began to work forthis employer.Using the format MM/DD/YYYY, enter the date your employment withthis employer ended.Describe the type of work performed for this employer.Enter the next most recent employer's name.Enter an X to enter additional employment information.Enter an X if you do NOT need to enter additional employmentinformation.
  849.     CONTINUATION OF BENEFITS SECTION - EMPLOYMENT INFORMATION    (SECTION 1 OF 1) 6.  Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed:  7. Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed:  8. Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed:  9. Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed: 10. Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed:     Do you need additional space?       Yes       No
  850. This required section allows you to include employment information.Enter an X if you want to complete screens regarding your employmenthistory.  Generally, Social Security will require your workexperience for each employer during the past fifteen years.Enter the most recent employer's name.Enter the employer's street address.Enter the employer's extended street address.Enter the city in which your employer is located.Enter the state/province in which the employer is located.  Press[F8] to select a state from the selection box.Enter your employer's zip/postal code.Using the format MM/DD/YYYY, enter the date you began to work forthis employer.Using the format MM/DD/YYYY, enter the date your employment withthis employer ended.Describe the type of work performed for this employer.Enter the next most recent employer's name.Enter an X to enter additional employment information.Enter an X if you do NOT need to enter additional employmentinformation.
  851.     CONTINUATION OF BENEFITS SECTION - EMPLOYMENT INFORMATION    (SECTION 1 OF 1) 11. Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed: 12. Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed: 13. Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed: 14. Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed: 15. Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed:     Do you need additional space?       Yes       No
  852. This required section allows you to include employment information.Enter an X if you want to complete screens regarding your employmenthistory.  Generally, Social Security will require your workexperience for each employer during the past fifteen years.Enter the most recent employer's name.Enter the employer's street address.Enter the employer's extended street address.Enter the city in which your employer is located.Enter the state/province in which the employer is located.  Press[F8] to select a state from the selection box.Enter your employer's zip/postal code.Using the format MM/DD/YYYY, enter the date you began to work forthis employer.Using the format MM/DD/YYYY, enter the date your employment withthis employer ended.Describe the type of work performed for this employer.Enter the next most recent employer's name.Enter an X to enter additional employment information.Enter an X if you do NOT need to enter additional employmentinformation.
  853.     CONTINUATION OF BENEFITS SECTION - EMPLOYMENT INFORMATION    (SECTION 1 OF 1) 16. Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed: 17. Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed: 18. Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed: 19. Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed: 20. Name of employer:     Address:     Address:     City:     State:     Zip Code:     Beginning date:     Ending date:     Type of work performed:
  854. This required section allows you to include employment information.Enter an X if you want to complete screens regarding your employmenthistory.  Generally, Social Security will require your workexperience for each employer during the past fifteen years.Enter the most recent employer's name.Enter the employer's street address.Enter the employer's extended street address.Enter the city in which your employer is located.Enter the state/province in which the employer is located.  Press[F8] to select a state from the selection box.Enter your employer's zip/postal code.Using the format MM/DD/YYYY, enter the date you began to work forthis employer.Using the format MM/DD/YYYY, enter the date your employment withthis employer ended.Describe the type of work performed for this employer.Enter the next most recent employer's name.
  855.     CONTINUATION OF BENEFITS SECTION - RETIREMENT    (SECTION 1 OF 1)                               RETIREMENT BENEFITS     Depending on your situation, you may need some or all of the following     in making an application to obtain Social Security retirement     benefits.  This checklist will be printed for your use in preparing to     apply for Social Security retirement benefits.        * Social Security number        * Birth Certificate        * Your W-2 forms or your complete tax return (including Schedule          SE) for the most recent year        * Your spouse's birth certificate and Social Security number, if          your spouse is also applying for benefits        * Children's birth certificates and Social Security numbers, if          applying for children's benefits        * Checking or savings account information if you want your benefits          directly deposited to your checking or savings account        * Any other Social Security number under which you or your          dependents have received Social Security payments
  856. This required section serves as a checklist of what is needed inorder to apply for Social Security Retirement Benefits.
  857.