Cover Sheet for {claimantName}

I have applied for disability online. I understand that the information I provided and sent to SSA electronically will be used in making a decision on this claim for benefits.

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{claimantMultiLineAddress}

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{claimantPhone}

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I have attached the following items (check all that apply):

☐ Medical Release Form (Authorization to Disclose Information to the Social Security Administration)

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☐ Other (Please list below)

Name of the person completing this application:

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Mail to:

{foAddress}