Disability Report - Appeal

Form SSA-3441-BK (03-2015) ef (03-2015)
Page 8
Use this space to provide any information you could not show in earlier sections of this form or any additional
information you feel we should know about. Please be sure to include the number of the question you are answering
(For example, 3A, 4D, etc.).
Date Report Completed MM/DD/YYYY:
SECTION 10 – REMARKS
Page 10/10
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