UNITED STATES COURT OF APPEALS, SIXTH CIRCUIT FACT SHEET FOR SOCIAL SECURITY APPEALS 6th Cir. R. 28(c) requires that counsel for the appellant and for the appellee file a one-page fact sheet in all social security appeals. The fact sheet should be the same size as the pages in the brief. It should be placed in the briefs of the parties immediately following the table of contents and preceding the statement of issues presented for review. Use this form, 6CA-55. Case Name and Number: __________________________________________________ ________________________________________________________________________ Person Reporting:_______________________________________________________ 1. 2. 3. 4. 5. Claimant's birth date: _____________________________________________ Date of application: _______________________________________________ Date of expiration of covered status: ______________________________ School attendance through grade: ___________________________________ Jobs held for significant periods (cite to particular pages of administrative record): 6. 7. 8. 9. Last date claimant worked and job held then: If this claim is based upon injury, specify injury or injuries: If this claim is based upon disease, specify disease or diseases. Upon what medical reports does claimant rely to establish clinical support for disability? (cite to particular page(s) of administrative record): 10. Upon what medical or other reports does the Secretary rely to establish substantial employment capacity? (cite to particular page(s) of administrative record): 11. Which of ( ) the ( ) the ( ) the the following agreed with the Secretary's decision? Administrative Law Judge United States Magistrate District Court 12. Are Supplemental Security Income Benefits involved in the appeal? ______ American LegalNet, Inc. 6CA-55 www.USCourtForms.com 12/98