Martinez Court Case
Recipient/Claimant Name: _____________________________
Recipient/Claimant SSN: _____________________________
Type of Title XVI Martinez Relief (select one):
Post-2006--Protective Filing Date:_________________________
_______ No subsequent claim after an N25 technical denial
_______ Subsequent claim with a disability determination or decision after an N25
technical denial
_______ Subsequent non-Martinez technically denied claim
______
Title XVI claim with a title II disability denial determination or decision for the
same period or later
_______ Title XVI claim with a title II allowance determination or decision with an
established onset date later than the title XVI application date of the N25 technically
denied claim
_______ FO can reinstate benefits-vacate subsequent medical denial determination
______ Age 18 Disability Redetermination
______ Other (please explain): _________________________________
_____________________________________________________
Pre-2007--Protective Filing Date: April 1, 2009
_______ No subsequent claim filed after 4/2009
_______ Subsequent claim filed after 4/2009 with a disability determination or decision
_______ Subsequent technically denied claim filed after 4/2009
______ Title XVI claim with a title II disability denial determination or decision for the
same period or later
_______ Title XVI claim with a title II allowance determination or decision with an
established onset date later than the title XVI application date of 4/1/2009
______ Other (please explain):