Social Security - Disability - SSI

Offices in Los Angeles, Orange, Riverside & San Bernardino Counties

800-803-5090

Representation

800-803-5090
S e r v i n g   S o u t h e r n   C a l i f o r n i a

If you live in the greater Southern California area and are interested in representation, please complete this Disability Information form and we will contact you as soon as possible!
Name [First, M.I., Last]:
Age:
Address:
City:
Telephone Number:
If yes, what was the denial date?
Zip:
E-mail Address:
If yes, when did you apply?
Date you last worked?
Why did you stop working?
What was your Job description/title?
Have you applied for Social Security Disability and/or SSI:
Have you been denied?
Are you working now?
Please describe all of the impairments that prevent you from working:
Bold = Required field
When did you become disabled?
Are You Under the Care of a Doctor or Therapist?

If you would rather download the form to fill out and fax,
please click here. Fax: 909-796-3402

Name
Phone Number
E-Mail Address
How can we help you?
Bold=Required field

For General Information, please fill out the following form. For more detailed information click here.

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