Last Update: 9/13/05 (Transmittal I-4-15)
EXAMINATION OF EVIDENCE
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In the case of _______________________________ (Claimant) |
Claim for _______________________________ (Social Security Number) |
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_______________________________ (Wage Earner) |
_______________________________ (Social Security Number) |
DESCRIPTION OF ADDITIONAL EVIDENCE
(List Additional Evidence Here)
Claimant to check appropriate statements:
___ I examined the above listed evidence and have no comments to make.
___ I examined the above listed evidence and my comments are as follows: (Use reverse side if necessary.)
___ I have no further evidence to submit.
___ I am submitting the following evidence:
___ I do not wish the evidence to be forwarded to my treating doctor.
___ I wish the evidence to be forwarded to my treating doctor for comments on it.
The name and address of my treating doctor is:
___ I do not wish to request a supplemental hearing to discuss this evidence.
___ I wish to request a supplemental hearing to discuss this evidence.
___ I do not wish to question, either orally or in writing, the author(s) of this (these) report(s).
___ I wish to question, either orally or in writing, the author(s) of this (these) report(s).
The claimant did not respond to our 10-day letter.
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__________________ |
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(Signature/Title of Social Security Employee) |
(Date) |