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Fact Sheet For Social Security Appeals - Maine

Fact Sheet For Social Security Appeals Form. This is a Maine form and can be used in District Court Federal .
 Fillable pdf Last Modified 5/17/2005
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UNITED STATES DISTRICT COURT DISTRICT OF MAINE FACT SHEET FOR SOCIAL SECURITY APPEALS: PLAINTIFF (For each item, cite specific page of record) Case Name: _____________________ _________________________________ 1. Type of application: ___________________ ___________________________ 2. Date of application: ______________________________________________ 3. Disability onset date: _____________________________________________ 4. Date of expiration of Insured Status: _________________________________ 5. Vocational factors: _______________________________________________ Year of Birth: ___________________ Age: ___________ (at time of hearing) Education (last grade completed): __________________________________ Past work experience: _______ ____________________________________ _____________________________________________________________ _____________________________________________________________ Last date worked and job held: ____________________________________ _____________________________________________________________ 6. Basis of ALJs decision: ___________________________________________ (nonsevere impairment, ability to return to prior work, Grid, vocational testimony, etc.) 7. If claim is based on a specific injury, specify injury: 8. If claim is based on disease(s), specify disease(s): **During your argument, please refer to specific medical reports relied upon as clinical support for disability.**
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