Sample SOAR Application Packet - Adult

By SAMHSA SOAR TA Center

Here are examples of completed SSA and SOAR Forms using information from a fictitious SSI/SSDI applicant.

These are scanned images. If you have accessibility issues, please contact us at soar@prainc.com. 

THIS SAMPLE PACKET IS FOR A FICTIONAL APPLICANT NAMED "ANNETTE FARNSWORTH," AND IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY.  THESE FORMS ARE NOT TO BE USED FOR THE SOAR ONLINE COURSE PRACTICE CASE.

Sample Completed SOAR Application Packet for an Initial Claim (Updated 10/04/19)

Sample Completed Appeal Forms (Updated 01/28/16)

  • SSA-561: Request for Reconsideration
  • HA-501: Request for Hearing by Administrative Law Judge
  • SSA-3441: Disability Report - Appeal
  • SSA-827: Authorization to Disclose Information
  • SSA-3288: Consent for Release of Information