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Quick Disability Benefit Evaluation

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Disability Benefits Evaluation Request

The form below contains eleven (11) parts. It will take at least twenty (20) minutes to complete. Depending on your unique situation, completing this form may be a lengthy process. The information requested in this form is the same kind of information we would request from you on your initial consultation to our office. Completing this form does not obligate you in any way, nor does it obligate our firm to represent you. This form is simply a tool for helping us evaluate your potential for acquiring disability benefits from the Social Security Administration.

Completing this Form

You will need some fair amount of information on hand to complete this form. You might find it easier to print our paper-based form and use it. If you would like to complete the questionnaire offline on paper, click on the print button below. If you have not already done so, call our office to schedule a consultation and be sure to bring the completed forms with you then.

Completing this form online does not replace a consultation with our attorneys. Consultations are cost and risk-free. Completing this form online will save you time at your initial consultation, and you will not have to provide this information again. The more thorough you are in responding, the fewer questions our paralegals will have to adequately prepare for your consultation with your attorney.

If you have not already contacted our office, we will use your preferred method of contact to setup your consultation.

QUICK Disability Benefit Evaluation Questionnaire

I understand this is a request for an evaluation for Social Security Disability Benefits, and that I am not forming an obligatory relationship with David Gantt Law Office by completing this evaluation request form. *
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