20 CFR 404.1503b(c) & 416.903b(c)

Evidence From Excluded Medical Sources of Evidence

BBA 812 - Model Repsonse - For Sections 208 or 1632 of the Act

20 CFR 404.1503b(c) & 416.903b(c)

OMB: 0960-0803

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WRITTEN STATEMENT
REGARDING SECTION 223(d)(5)(C)
OF THE SOCIAL SECURITY ACT –
DO NOT REMOVE

I, [Name and Title], was convicted of a felony under section 208 or 1632 of the Social Security
Act on [Date of Felony Conviction].


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