Law Office of Sema E. Lederman

P. O. Box 16189
Chapel Hill, NC 27514-6189 clear

toll-free: 888-529-3678

888-LAW FOR U clear

local: 919-968-6402
fax: 919-968-6403

lederman@socialsecurity-nc.com

LAW OFFICE OF SEMA E. LEDERMAN

SOCIAL SECURITY DISABILITY LAW

For a free, confidential and secure CASE REVIEW, please fill out the following Social Security Disability evaluation application. Click on the Submit button below when you are done.

(*) indicates required field.

First Name *	Last Name *
Street Address *
City *
State *	Zip (5 digit)
Home telephone number * - -	Email address (if applicable)
Cell phone number - -
Your Age *	Highest education level *
Onset date of your disability
Currently working? YES NO	Work Experience Description
Applied for Disability? YES NO	If yes, status of claim
Under doctor's care? YES NO	Attorney currently on case? YES NO
IMPAIRMENTS — Indicate all that apply: *
Arms/Hands Asthma Back/Neck/Leg pain Diabetes mellitus Digestive problems	Heart disease/Hypertension HIV/Cancer Mental health symptoms Obesity Other

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