_____________________________________________________________________
Potential
Interim Benefit
Case
Claimants SSN: ____-___-___ Wage Earners SSN:___-___-___
Claimants Name: ____-___-___ Telephone:___-___-___
In Care of:______
Street:______ City:_______ State:_______ Zip:______
[ ] Title II (Only) [ ] Title XVI (Only) ([ ] SSI Child)[ ] Concurrent Title II and
XVI
ALJ:_____ Hearing Office:________
ALJ Decision Date __/__/__ (mm/dd/yyyy) 110 days: __/__/__ To OAO, Exec. Dir. Ofc.:
__/__/__
WC: [ ]Yes [ ]No
Application Date: __/__/__ Onset Date Established: __/__/__
Date of Birth: __/__/__ Remand Date: __/__/__
Representatives Name: ___ Telephone (__)__-__
Street:______ City:_______ State:_______ Zip:______
Prisoner Suspension [ ]Yes [ ]No Branch: ______
Comments:____
___________________________________________________________________
___________________________________________________________________
Contact to Start: __/__/__ Contact to Stop: __/__/__
Office Contacted:
Title II (Office/FAX)Title XVI:____
E-Mail:_____
TOELs=
Additional Comments:____
_____________________________________________________________________