If you have access to the Internet you may access the Disability Report Form - Appeal instructions at http //www. ssa.gov/online/ssa-3441. html. HOW TO COMPLETE THIS FORM Print or write clearly. DO NOT LEAVE ANSWERS BLANK. DISABILITY REPORT - APPEAL - Form SSA-3441-BK READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM We will use the information that you give us on this form to update your ...
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Secretar y of State
Affirmati on of Correction
Secre tary of State
Vehicle Services Department
014 Howlett Bldg.
Springfie ld, IL 62756
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