SSA-789-U4 2012 free printable template

1. SIGNATURE OF WITNESS ADDRESS NUMBER AND STREET CITY STATE ZIP CODE Form SSA-789-U4 04-2012 EF 04-2012 CLAIMS FILE PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE Sections 205 a 1631 c 1 A and B of the Social Security Act as amended authorize us to collect the information on this form. We will use this information to determine your potential eligibility for benefit payments and to help us decide if we need additional information. Furnishing us this information is voluntary. Form Approved OMB...

How to fill out SSA-789-U4

How to fill out SSA-789-U4

1. Obtain Form SSA-789-U4 from the Social Security Administration website or your local Social Security office.
2. Begin by filling in your personal information, including your name, Social Security number, and date of birth at the top of the form.
3. Provide information about your current medical condition and any treatments you are receiving.
4. Fill out the section regarding your work history, including the dates and types of jobs you have held.
5. Detail any clinics, hospitals, or healthcare providers you have visited for your condition, including their names and addresses.
6. Review your form for completeness and accuracy.
7. Sign and date the form before submitting it to the designated Social Security office.

Who needs SSA-789-U4?

1. Individuals applying for Social Security disability benefits who have a mental impairment should submit SSA-789-U4 to provide necessary medical and psychological information.

People Also Ask about

What is SSA 789 form from Social Security?

A. Overview of the SSA-789 The claimant, an appointed representative, a representative payee or other third party filing on the claimant's behalf can use the SSA-789 Request for Reconsideration to request reconsideration on an initial disability cessation determination.

What is SSA definition of qualifying impairment?

We consider you to have a qualifying disability under our rules if all the following are true: You cannot do work and engage in substantial gainful activity (SGA) because of your medical condition. You cannot do work you did previously or adjust to other work because of your medical condition.

What is an example of a disability dire need letter?

To Whom It May Concern: I am writing to request consideration as a person in critical need for my Social Security disability. I require my claim to be processed as a dire need case because I cannot afford food, medicine, or shelter. I am attaching (list your attachments) to prove my circumstances are critical.

Who fills out SSA 795?

Form SSA-795, Statement of Claimant or Other Person, is used by a third-party who needs to make a statement about the applicant's employment or wages.

How do I write a dire need letter for disability?

When writing your letter, make sure to share as much information about your current situation as possible. Explain why you consider it a dire need situation. Be sure to give details about why your situation is dire. Also, describe what you believe might happen if you are not approved quickly for assistance.

What is considered dire need for disability?

A dire need situation exists when a claimant alleges any of the following circumstances: The claimant is without food and is unable to obtain it. The claimant lacks medicine or medical care and is unable to obtain it, or access to necessary medical care is restricted because of a lack of resources.

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What is SSA-789-U4?

SSA-789-U4 is a form used by the Social Security Administration (SSA) to collect information regarding an individual's potential eligibility for disability benefits.

Who is required to file SSA-789-U4?

Individuals who are applying for Social Security disability benefits and need to provide detailed information about their impairments are required to file SSA-789-U4.

How to fill out SSA-789-U4?

To fill out SSA-789-U4, applicants should provide personal information, details about their disabilities, and any relevant medical information. It is essential to be thorough and accurate in the responses.

What is the purpose of SSA-789-U4?

The purpose of SSA-789-U4 is to gather comprehensive information about an applicant's medical conditions and limitations to assess their eligibility for Social Security disability benefits.

What information must be reported on SSA-789-U4?

The SSA-789-U4 requires information about the applicant's medical history, the nature of their disability, treatments received, work history, and the impact of their condition on daily activities.