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The More Information You Can Provide Regarding Your Social Security Disability Case or SSI Appeal, The Better We Will Be Able To Assist Your Needs

Tell Us About Your Case

Personal Information:
First Name:	Last Name:	Age:	Zip Code:


*If contacting us for someone else, please give the disabled person's information above and your name and relationship to the disabled person here.
Parent's Name:


Contact Information:
Telephone 1:	Telephone 2:	Email Address:


Work Information:
Are You Working?	Date you last worked:	Type of Work:
Yes No

Disability Information:
What Is Your Disability?		When Did You Become Disabled?


Disability Information:
Have You Applied for Social Security?	If Yes, When Did You Apply?
Yes No

Have You Been Denied Yet?	If Yes, When Were You Denied?
Yes No


All information submitted will be treated in the strictest confidence.

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	Social Security Disability and SSI Applications and Appeals Haase & Haase, Inc., P.C Serving San Antonio, All South Texas & The Hill Country San Antonio (210) 824-3239 Toll Free: 1-800-491-8666 Email: ssa-help@haaseonline.com


	Home \| About Richard T. Haase \| Tell Us About Your Case Contact Us - Location Of Office \| What Our Clients Say About Us \| En Español P.O. Box 6539, San Antonio, Texas 78209 \| Phone: (210) 824-3239 ©2009 Haase & Haase, Inc. All Rights Reserved. This site is not affiliated with, or endorsed by the Social Security Administration. Past performance is not a guarantee of future results.