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Social Security Forms

PRE-APPLICATION FORMS

Workers Compensation/Public Disability Questionnaire

SSA-546 Print and fill out by hand (67 kb)
SSA-546 Fill out online, then print (159 kb)

Disability Report-Adult

SSA-3368 Print and fill out by hand (125 kb)
SSA-3368 Fill out online, then print (426 kb)

Work History Report

SSA-3369 Print and fill out by hand (80 kb)
SSA-3369 Fill out online, then print (385 kb)

HEARING REQUEST FORMS

Claimant’s Statement when ‘Request for Hearing’ is filed and issue is Disability

HA-4486 Print and fill out by hand (101 kb)
HA-4486 Fill out online, then print (157 kb)

HEARING PREPARATION FORMS

Disability Report Appeal

SSA-3441-BK Print and fill out by hand (72 kb)

Medication List

HA-4632 Print and fill out by hand (46 kb)
HA-4632 Fill out online, then print (65 kb)

Recent Work History

HA-4633 Print and fill out by hand (216kb)
HA-4633 Fill out online, then print (231 kb)

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Garden Grove, CA 92843

(714) 750-6000

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El Monte, CA 91731

(626) 582-8260

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Serving Orange County: Aliso Viejo, Anaheim, Balboa Island, Brea, Buena Park, Capistrano Beach, Corona Del Mar, Costa Mesa, Coto de Caza, Cowan Heights, Cypress, Dana Point, El Modena, El Toro, El Toro Marine Base, Foothill Ranch, Fountain Valley, Fullerton, Garden Grove, Huntington Beach, Irvine, La Habra, Laguna Beach, Laguna Hills, Laguna Niguel, Lake Forest, Leisure World, Lemon Heights, Los Alamitos, Mission Viejo, Modjeska Canyon, Newport Beach, Orange, OC, Orange Park Acres, Placentia, Rancho San Margarita, Rossmoor, San Clemente, Santa Ana, Seal Beach, Silverado Canyon, Stanton, Sunset Beach, Surfside, Tustin, Villa Park, Westminster, Yorba Linda

Serving Riverside County: Aguanga, Anza, Arlington, Calimesa, Casa Blanca, Cherry Valley, Corona, Corona Hills, Edgemont, El Cerrito, Gilman, Glen Avon, Glenn Valley, Hemet, High Grove, Home Gardens, Homeland, Hot Springs, Idyllwild, La Sierra, Lake View, Mead Valley, Meadow Brook, Mira Loma, Moreno Valley, Mt. Lanter, Murrieta, Norco, Nuevo, Pedley, Perris, Quail Valley, Riverside, Rodea, Romoland, Sage, San Jacinto, Santa Ana Canyon, Soboba, Sun City, Temecula, Temescal Canyon, Vail Lake, Valle Vista, Wildomar Lake, Winchester

Serving Los Angeles County: Arleta, Bel Air, Canoga Park, Chatsworth, Crenshaw, Downtown Los Angeles, Eagle Rock, Echo Park, Encino, Granada Hills, Highland Park, Hollywood, Koreatown, La Brea, Lakeview Terrace, Los Feliz, Mar Vista, Miracle Mile, Mission Hills, North Hills, North Hollywood, Northridge, Pacific Palisades, Pacoima, Panorama City, Porter Ranch, Reseda, San Pedro, Sepulveda, Sherman Oaks, Silverlake, Studio City, Sunland, Sun Valley, Sylmar, Tarzana, Toluca Lake, Tujunga, Van Nuys, Venice, Watts, West Los Angeles, Westwood, Winnetka, Woodland Hills