SSA-3441

DISABILITY REPORT - APPEAL - Form SSA-3441-BK

Download and Print the SSA-3441

READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM

We will use the information that you give us on this form to update your disability report information for your appeal. We will use the form to update your disability information since you last completed a disability report. Please complete as much of the form as you can. If you need help, your interviewer will help you finish it. If you have an appointment for an interview by telephone, have the form ready to discuss with us when we call you. If you have an appointment for an interview in our office, bring the completed form with you or mail it ahead of time, if you were told to do so. If you have access to the Internet, you may access the Disability Report Form - Appeal instructions at
http://www.ssa.gov/online/ssa-3441.html
.
If you are filling out the form for someone else, please provide information about him or her. When a question refers to "you," "your," or the "Disabled Person," it refers to the person who is applying for or has been entitled to disability benefits.


HOW TO COMPLETE THIS FORM

Print or write clearly.

DO NOT LEAVE ANSWERS BLANK. If you do not know the answers, or the answer is "none" or "does not apply," please write: "don't know," or "none," or "does not apply."
IN SECTION 3, PUT INFORMATION ON ONLY ONE

DOCTOR/HMO/THERAPIST/OTHER/HOSPITAL/CLINIC IN EACH SPACE.

Each address should include a ZIP code.
Each telephone number should include an area code

DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THIS FORM. However, you can get help from other people, like a friend or family member.

Be sure to explain an answer if the question asks for an explanation, or if you want to give additional information.

If you need more space to answer any questions or want to tell us more about an answer, please use Section 10 - REMARKS on Page 7, and show the number of the question being answered.

And much more...