I-4-1-92.Exhibit - Sample Annotated Exhibit List — Six Part Folder

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

LIST OF EXHIBITS

Claimant:                     [Claimant Name]                               SSN:             [SSN]

[Cross-ref Name:]      [Xname]                                            [Xref SSN:] [XSSN]

 

Exh. No.

Part No.

Description

No. of Pages

PAYMENT DOCUMENTS/DECISIONS

[Exh No.]

A

[Description of Exhibit]

[No. of Pages]

JURISDICTIONAL DOCUMENTS/NOTICES

[Exh No.]

B

[Description of Exhibit]

[No. of Pages]

NON-DISABILITY DEVELOPMENT

[Exh No.]

D

[Description of Exhibit]

[No. of Pages]

DISABILITY-RELATED DEVELOPMENT AND DOCUMENTATION

[Exh No.]

E

[Description of Exhibit]

[No. of Pages]

LIST OF EXHIBITS

Claimant:                     [Claimant Name]                               SSN:             [SSN]

[Cross-ref Name:]      [Xname]                                            [Xref SSN:] [XSSN]

Exh. No.

Part No.

Description

No. of Pages

MEDICAL RECORDS

[Exh No.]

F

[Description of Exhibit]

[No. of Pages]