I-4-3-115.Sample — Examination of Evidence

Last Update: 9/13/05 (Transmittal I-4-15)

EXAMINATION OF EVIDENCE

In the case of

_______________________________

(Claimant)

Claim for

_______________________________

(Social Security Number)

_______________________________

(Wage Earner)

_______________________________

(Social Security Number)

DESCRIPTION OF ADDITIONAL EVIDENCE

(List Additional Evidence Here)

  1. 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).

  2. The claimant did not respond to our 10-day letter.

____________________________________

__________________

(Signature/Title of Social Security Employee)

(Date)