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Social Security Contact Form

Full Name (First, M.I., Last):

Date of Birth

Address

City (required)

State

Telephone Number

Email Address

Are You Currently Working? Yes No

If you are not working, enter the date you last worked?

Describe the type of work you do

On what date did you become disabled?

Have you filed an application for a Social Security disability claim? Yes No

If yes, when did you apply?

At what stage is your claim?

Are you currently under a doctor's care? Yes No

Please provide details about your injury or the disease that is preventing you from working

The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time sensitive information should not be sent through this form.

Dallas / Fort Worth :: Houston :: South Texas :: VIEW ALL OFFICE LOCATIONS

No attorney fees or costs unless you win your claim. No attorney fees are paid without approval of the Social Security Administration. Consultation in the Houston Galleria, Plano, Westchase, Woodlands.

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