Disability Report-Appeal 20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c), 405 subpart C, 422.140

Proposed text for RS002

Insert underneath/following the 2000 character text box

Information About the Person Completing this Report

o I completed this form for myself. (Radio button, if clicked it grays out the remainder)

o I completed this form for another person. (Radio Button that opens text boxes below)

Name of person completing this report

Address

City

S tate

Zip Code

Email Address

PROPOSED i3441 ADDITION TO REVIEW &

SEND COLLECTION SCREEN

199601