PRE-APPLICATION FORMS
Workers Compensation/Public Disability Questionnaire
SSA-546 Print and fill out by hand (67 kb)
SSA-546 Fill out online, then print (159 kb)
Disability Report-Adult
SSA-3368 Print and fill out by hand (125 kb)
SSA-3368 Fill out online, then print (426 kb)
Work History Report
SSA-3369 Print and fill out by hand (80 kb)
SSA-3369 Fill out online, then print (385 kb)
DEVELOPMENT FORMS
Function Report – Adult
SSA-3373 Print and fill out by hand (426 kb)
SSA-3373 Fill out online, then print (426 kb)
Function Report – Adult Third Party
SSA-3380 Print and fill out by hand (426 kb)
SSA-3380 Fill out online, then print (426 kb)
APPEAL FORMS
Claimant’s Statement when ‘Request for Hearing’ is filed and issue is Disability
Disability Report Appeal
SSA-3441-BK Print and fill out by hand (72 kb)
SSA-3441-BK Fill out online, then print (72 kb)
HEARING PREPARATION FORMS
Claimant’s Medical Treatment
SSA-4631-BK Print and fill out by hand (72 kb)
Medication List
HA-4632 Print and fill out by hand (46 kb)
HA-4632 Fill out online, then print (65 kb)
Recent Work History
HA-4633 Print and fill out by hand (216kb)
HA-4633 Fill out online, then print (231 kb)
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