Benefit Counseling Form

Are you between the ages of 18-64?
YesNo

Are you currently receiving SSI?
YesNo

Are you currently receiving SSDI?
YesNo

Are you a ticket holder?
YesNo

Are you interested in returning to work with the ultimate goal of getting off Social Security completely and becoming self-sufficient?
YesNo

Have you met with a Certified Work Incentives Coordinator (CWIC) to review how work will impact benefits?
YesNo

Have you met with any other EN or DOR?
YesNo