What type of case are you appealing from:
Civil
Criminal
Administrative
Other
If Civil or Criminal tell us:
What Court you lost in -
To what Court are you taking an appeal-
On what date was the Judgment -
What attorney(s) represented you -
If Administrative tell us what Agency denied you and
what was the issue?
If you indicated “Other” state what your
matter is:
If you are appealing a denial of Social Security
benefits tell us:
What are your physical or mental impairments that
keep you from working?
Have you applied for SS Benefits?
yes
no
When did you apply?
When were you last denied?
What level last denied you?
Initial Application
Reconsideration
Administrative Law Judge Hearing
Appeals Council
U. S. District Court
U. S. Court of Appeals
Please explain any other facts you think would help
us in evaluating your case:
How were you referred to us?
TV
Yellow Page
White Pages
Friend
Lawyer or Doctor
Other
Saw Victor Makris speak in a seminar
If a person referred you to us please state their
name:
