FREE SSDI / SSI Federal Court Appeal Evaluation Please fill out the form below (* = required): * First Name: * Last Name: Email: * Phone: * Street: * City: * State/Province: –Select State– AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY * Zipcode: * Age Group: –Select Age Group– 17 & Under 18-22 23-44 45-49 50-54 55-59 60-64 65+ * Are you working?: Yes No * Are you currently collectingSocial Security benefits?: Yes No Notice of Appeals Council Action Date: (Enter the date of your Appeals Council denial. Click here to see a sample copy)
