IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO _____________DIVISION FACT SHEET FOR SOCIAL SECURITY APPEALS: PLAINTIFF (For each item, cite specific page of record) Case Name: ______________________________________________________________________ 1. 2. 3. 4. 5. Type of application: __________________________________________________________ Date of application: __________________________________________________________ Disability onset date: _________________________________________________________ Date of expiration of insured status: _____________________________________________ Vocational Factors: __________________________________________________________ Date of Birth: __________ Age: __________ (At time of hearing) Education: (last grade completed): ______________________________________________ Past work experience: ________________________________________________________ ___________________________________________________________________________ Last date worked and job held: _________________________________________________ ___________________________________________________________________________ 6. Basis of ALJ's decision _______________________________________________________ (nonsevere impairment, prima facie case, Grid, vocational testimony, etc.) If claim is based on specific injury, specify injury: If claim is based on diseases; specify disease: During your argument, please refer to specific medical reports relied upon as clinical support for disability.
7. 8. 9.