Disability Report - Child (Paper) SSA-3820

Disability Determination Ready Claim
Certification Statement
 By checking the box, I certify that all of the following statements
are true:
I wish to have my claim considered in the Disability Determination
Ready Claim process.
I have submitted all evidence known to me, without redaction, that
relates to whether I am blind or disabled.
I am not aware of any additional evidence that relates to whether I
am blind or disabled which has not already been submitted.
If a consultative examination is needed to determine my claim, I
will cooperate with that process, including attending the
examination.
If I become aware of additional evidence that relates to whether I
am blind or disabled, I will submit that evidence or notify the
Agency about its existence.
The following Paperwork Reduction Act Statement applies to the Certification Statement
for the following OMB approvals: 0960-0004, 0960-0010, 0960-0144, 0960-0229, 0960-0444,
0960-0577, 0960-0579, 0960-0618, 0960-0622, and 0960-0623.
Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget
(OMB) control number on the attached form. We estimate that it will take under a minute to sign
this Certification Statement. Send only comments regarding this burden estimate, the burden
estimate on the attached form, or any other aspect of this collection, including suggestions for
reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.