Disability Report - Adult, 20 CFR 404.1512 and 416.912

Proposed text for RS002

Insert underneath/following the 3000 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 i3368 ADDITION TO REVIEW &

SEND COLLECTION SCREEN

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