What is your state of residence?
What phone number and time of day are best for you to be contacted?
In the following tables, fill in the values based upon all assets owned by the people currently living in your "home" that can be counted as part of your "household group".
Household Group - Answer this question as if you are one of the adults responsible for supporting the household. Based upon this, the following individuals are to be
included if they are living in your home: Yourself, your spouse, your partner if you have a child between the two of you who is not married, under 18 and still living in
your home, any natural or adopted children if they are under 18 and not married. Do not include your parents if you are over 18 years old.
Please provide their name(s) and age(s):
Does the patient have any of the following conditions:
Please provide the name of the medical conditions preventing patient from working:
Would the patient be willing to apply for Social Security for this condition?
Thank you very much! Now just click on the "Done" button...