Social Security Intake

Contact Information

First we need some contact information for our records. (If you are helping someone fill out this form, please enter their information, not yours.)

First Name(Required)

Middle Name(Required)

Last Name(Required)

Name of Person Assisting You

If a caseworker or someone else is helping you with this form, please provide their name and contact information here.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Phone Number(Required)

Additional Phone Number

How did you hear about Cooper Law?(Required)

Preliminary Qualification Outcome

Contract Qualification Outcome

Confirmation

Do you want to continue?(Required)

If you think you want to work with us, we will need to collect some additional information from you in order to pursue your claim. If you don't want to work with us you can quit now.

Yes

Additional Information

Alternative Mailing Address/Instructions

If the address you gave me earlier is not the best place to send mail to you, please give us the best mailing address for you with any additional instructions.

Additional instructions could be a description like "case worker's address" or "ATTN: Pat Smith."

Social Security Number(Required)

Security Questions

The next 3 questions are security questions we need to keep on file for when we call Social Security on your behalf. They will verify our identity using these questions before they will talk to us about your claim.

Note: spelling is not important. We just need to be able to provide the answers verbally over the phone.

FAQs/frequent concerns:

Parent(s) are deceased. That's OK. We still need their names. These questions are for identification only.
“I don’t want my parents alerted or involved in my claim.” They won't be. Parents are never involved unless a client specifically lists them as an alternate contact.
Client may not know answers. If they are unsure, write “unknown” and move on. This is common for clients who are adoptees or refugees.
“I was adopted." Collect adopted and biological parents' names if possible and note which is which.
“I don’t know my father," or "I don’t think he is listed on my birth certificate,” etc. This is fine—just note this in case we run into trouble with the security questions.

Father's Full Name(Required)

Mother's Name Before Marriage/Maiden Name(Required)

What city and state were you born in? (Or city and country if born outside the US.)(Required)

What Minnesota county do you currently live in? (Or if you are homeless, in what county do you spend most of your time?)(Required)

Backup Contact

We want to make sure we can get in touch with you. Please let us know who we can contact if we aren't able to reach you.

Backup Contact Name(Required)

Relationship to You(Required)

Backup Contact Phone Number(Required)

Backup Contact Email

Social Security Disability Intake

Contact Information

Preliminary Qualification

Preliminary Qualification Outcome

Contract Qualification

Contract Qualification Outcome

Confirmation

Additional Information

Security Questions

Backup Contact

contact info

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