DISABILITY APPLICATION

DISABILITY APPLICATION

E-mail*

date

Name of applicant*

Date of Birth*

age

sex

Select or enter value

address of personal residence*

city*

state*

zip code*

mailing address (if different than above)

Email*

Phone Number*

type of residence

Select or enter value

Parcel Number

File Upload*

You are required to upload a copy of your valid driver's license or state ID AND either your "Notice of Awards" letter from social security OR your "BPQY" from social security.

Drag and drop files here or

I have read and understand that my application will not be processed unless I upload a copy of BOTH a valid driver's license and EITHER a Notice of Award letter OR BPQY*

Send me a copy of my responses

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