I-4-3-113.Sample — List of Additional Evidence

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

In the case of

_______________________________

(Claimant)

Claim for

_______________________________

(Social Security Number)

_______________________________

(Wage Earner)

_______________________________

(Social Security Number)

LIST OF ADDITIONAL EVIDENCE

  1. Medical report from Robert T. Jones, M.D. dated July 5, 1988.

  2. Professional qualifications of Robert T. Jones, M.D.