NOTE: THIS IS NOT THE SOCIAL SECURITY ADMINISTRATION (SSA). BY COMPLETING THIS FORM, YOU WILL RECEIVE THE NAME OF AN ATTORNEY WHO HANDLES SOCIAL SECURITY DISABILITY CLAIMS. YOU MUST CONTACT THAT ATTORNEY DIRECTLY. THERE IS NO GUARANTEE THAT THE ATTORNEY WILL CHOOSE TO REPRESENT YOU IN YOUR CLAIM FOR SOCIAL SECURITY DISABILITY OR SSI BENEFITS. IF YOU WANT TO CONTACT SSA, DO NOT COMPLETE THIS FORM; INSTEAD, CALL 1-800-772-1213 OR VISIT www.ssa.gov.

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