DEMPSEY, DEMPSEY & MOELLRING, P.C.

Attorneys at Law

MISSOURI & ILLINOIS

Reply to: Quincy Office

                  Vicki A Dempsey                                 236 North 6th Street                             716 Broadway, P.O. Box 510

                   D. Terrell Dempsey, III                       Quincy, Illinois. 62301                         Hannibal, Missouri. 63401    

                   Marcia Moellring                               Telephone (217) 222-2432                   Telephone ( 573) 221-2150    

                                                                                   Fax. (217) 222-3264                               Fax. (573) 221-2803                

 

Name: ___________________________________

Appointment Date: _____________________ Time:_______________

Check Box Quincy Office Hannibal Office

1) Please bring your denial letter to your appointment;

2) When was the last day you worked? _____/_____/_____

3) Where were you working and why did you quit ____________________________________________

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4) Have you worked five out of the last ten years? Yes No

5) Have you applied for Social Security? Yes No

6) What date did you give to the Social Security Administration as the date you became disabled? _____/_____/_____