Lisa R.J. Porter, Esq.

Admitted in OR and WA

Melissa N. Kenney, Esq.

Admitted in MD

Of Council: David B. Lowry

Admitted in OR and AZ

The preparation of a Social Security Disability case requires the gathering of considerable information. ( ) ( ) ( ) ( ) ( ( ( ( ) ) ) ) Please obtain for me a printout from your pharmacy for all medicines. Please send me a list of ALL of your medical, physical therapy, counseling, etc. appointments for the past 24 months. If you have not done so, please furnish me the names, addresses and telephone numbers of all witnesses. Please send me a copy of your disabled parking permit, or a copy of an application signed by your Doctor. Please send me a copy of 30 days of blood sugar readings. Please send me a copy of your hearing test results. Please send me the name, address and claim number for your old Workers Compensation case. Please send me a copy of all letters you have received from Social Security denying your disability claim. This includes your current claim, as well as any earlier claims that were denied by the Social Security Administration.

Whenever you answer questions or fill out a questionnaire for SSA, neither exaggerate or minimize your condition. SSA will deny your claim easily if you tell them what you can do, or you do not explain that you have problems doing these things. You want them to see the answers that reflect what you cannot do and why, or what you do only with difficulty and why. Any SSA questionnaires you fill out should be returned to ME and NOT to SSA. That way, I can make a copy and if you have said something unwise, or which might confuse SSA, we can talk about it. Thank you for your cooperation in this matter. VERY IMPORTANT: What is the name, address and telephone number of some one who DOES NOT LIVE WITH YOU, but will ALWAYS know where your are?

Name: Address: City/State/Zip Telephone: Relationship:

AUTHORIZATION FOR RELEASE OF INFORMATION I authorize ____________________________________________________________________ to disclose a copy of the health information described below regarding the following: Name: _____________________ SSN:___________________________ DOB:__________________________ To: KP Law LLC Attorneys At Law

The undersigned hereby authorizes attorney, Melissa N. Kenney, Lisa Porter, or any representative thereof, to obtain information, for the purpose of obtaining Social Security Benefits. PLEASE INITIAL ALL THE SPACES BELOW _____ All Physician/Hospital/Clinic/Emergency/Urgent Care/Dental/Physical Therapy records (including lab, x-ray, diagnostic/consultative summaries), including protected records (if applicable) This authorization does not curtail the ability or inability to the condition of general healthcare upon its receipt. _____ Billing Statements _____ Workers Compensation Records

16200 SW Pacific Hwy, Suite H-280 Portland, OR 97224 (503) 245-6309 (503) 245-6725 Fax

PROTECTED OR SENSITIVE INFORMATION: I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer be will protected under federal law. I also understand that federal or state law may restrict redisclosure of HIV/AIDS information, mental health information, genetic information and drug/alcohol diagnosis.

I authorize the release of the following protected or sensitive information:

PLEASE INITIAL ALL THE SPACES BELOW _____ Drug/Alcohol diagnosis/treatment/or referral _____ Psychological and/or psychiatric treatment _____ Genetic testing information PLEASE INITIAL ALL THE SPACES BELOW ______ ______ ______ Adult & Family Services/Senior Disabled Services Records (Medical and Mental Health Treatment Records) _____ Any and all School records and transcripts including all counseling/psychological records ______ I specifically consent to the FAXing of my records. All FAXed material will contain a confidentiality statement, however, understand confidentiality at the receiving end cannot always be guaranteed. Police records Employment records Federal, state income records _____ _______ Sexually transmitted diseases _______ AIDS/HIV test results, including RELATED high-risk behaviors

You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care service is if the health care services are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure. You may revoke this authorization, please send a written statement to KP Law LLC at the above address and state that you are revoking this authorization. Unless revoked earlier, this consent will expire 180 days from the date of signing or shall remain in effect for the period reasonably needed to complete the request. This authorization is in compliance with HIPAA PHOTOCOPIES OF THIS AUTHORIZATION ARE VALID AND MAY BE USED IN LIE OF THE ORIGINAL

Clients Name (Please print)___________________________________________ Dated:______________ Clients Signature __________________________________________________

___________________________________________________________________ Parent or Guardians Signature ___________________________________________________________________ 9/09/2011 Forms/AUTHO If signed as parent or guardian, this authorization shall apply to the records of the above mentioned individual ___________________________________ Name of Parent or Guardian of Client

This is a true copy of the original authorization document. A true copy shall be deemed to be the same as the original thereof.

Signature of Staff Person

Social Security Administration Consent for Release of Information TO Social Security Administration
______________________ Name ___________ Date of Birth

Form Approved OMB No. 0960-0566

___________________________ Social Security Number

I authorize the Social Security Administration to release information or records about me to:
Melissa N. Kenney Lisa R. Porter Nanette L Mitchell Leta Sanders Rahma Abdulaziz 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224

___X____ ___X____ ___X____ ___X____ ___X____ ___X____ _______

Social Security Number Identifying information (includes date and place of birth parents names) Monthly Social Security benefit amount Information about benefits/payments I received ______________ to _________________ Information aobut my Medicare claim/coverage from _____________to ________________ (specify)____________________________________________________________________ Medical records Record(s) from my file (specify)___________________________________________________ _____________________________________________________________________________

I am the individual to whom the information/record applies or that persons parent (if a minor) or legal guardian. I declare under penalty of perjury that I have examined all of the information on this form and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.
Signature: _____________________________________________________________________________________ (show signature names and addresses of two people if signed by a mark) Date:_________________________________ Relationship: ______________________________________

Form SSA-3288 (3-2005) EF (3-2005)

DEPARTMENT OF HEALTH AND HUMAN SERVICE SOCIAL SECURITY ADMINISTRATION/OFFICE OF HEARINGS AND APPEALS

Form Approved OMB No. 0960-0277 See Privacy Act Notice on Reverse

REQUEST FOR REVIEW OF HEARING DECISION

(Take or mail original and all copies to your local Social Security office)

1. CLAIMANT

2. WAGE EARNER, IF DIFFERENT

3. SOCIAL SECURITY CLAIM NUMBER

4. SPOUSE'S NAME AND SOCIAL SECURITY NUMBER (Complete ONLY in Supplemental Security Income Cases)

5. I request that the Appeals Council review the Administrative Law Judge's action on the above claim because:

Claimant is Disabled.

ADDITIONAL EVIDENCE
If you have additional evidence, submit it with this request for review. If you need additional time to submit evidence or legal argument, you must request an extension of time in writing now. If you request an extension of time, you should explain the reason(s) you are unable to submit the evidence or legal argument now. If you neither submit evidence or legal argument now nor within any extension of time the Appeals Council grants, the Appeals Council will take its action based on the evidence of record. IMPORTANT: Write your Social Security Claim Number on any letter or material you send us. SIGNATURE BLOCKS: You should complete No. 6 and your representative (if any) should complete No. 7. If you are represented and your representative is not available to complete this form, you should also print his or her name, address, etc. in No. 7.

DATE

ATTORNEY

Q NON-ATTORNEY

6. CLAIMANT'S SIGNATURE

7. REPRESENTATIVE'S SIGNATURE

PRINT NAME

Melissa N Kenney Esq. 16200 SW Pacific Hwy, Suite H-233 Portland OR 97224 503-245-6309
TELEPHONE NUMBER (INCLUDE AREA CODE) (CITY, STATE, ZIP CODE) ADDRESS

PRINT NAME

ADDRESS

(CITY, STATE, ZIP CODE)

TELEPHONE NUMBER (INCLUDE AREA CODE)

THE SOCIAL SECURITY ADMINISTRATION STAFF WILL COMPLETE THIS PART 8. Request received for the Social Security Administration on by:

(Title) 9

Servicing FO Code

(Address)

PC Code No G

Is the request for review received within 65 days of the ALJ'S Decision/Dismissal Yes G

10. If no checked: (1) attach claimant's explanation for delay; and (2) attach copy of appointment notice, letter or other pertinent material or information in the Social Security Office. 11. Check one: Q Initial Entitlement Q Termination or other 12. Check all claim types that apply: Q Retirement or survivors Q Disability - Worker Q Disability - Widow(er) Q Disability - Child Q SSI Aged Q SSI Blind Q SSI Disability Q Health Insurance - Part A Q Health Insurance - Part B Q Other -- Specify:

APPEALS COUNCIL OFFICE OF HEARINGS AND APPEALS, SSA 5107 Leesburg Pike FALLS CHURCH, VA 22041-3255

(RSI) (DIWC) (DIWW) (DIWC) (SSIA) (SSIB) (SSID) (HIA) (HIB)

Form HA-520-U5 (3-94) Destroy old stock

CLAIMS FOLDER

LisaR.J.Porter,Esq.
AdmittedinORandWA

MelissaN.Kenney,Esq.
AdmittedinMD

OfCouncil:DavidB.Lowry
AdmittedinORandAZ

Certified Mail

Appeals Council Office of Disability Adjudication and Review 5107 Leesburg Pike Falls Church, VA 22041 RE: S.S.N.: Dear Appeals Council: On behalf of the above claimant, we request a review of the decisions of ALJ * dated *. I request a copy of the tapes of the hearings and all exhibits. I request 45 days from receipt thereof in which to submit additional evidence and/or argument. Thank you. Yours truly,

Melissa N Kenney, Esq. MNK/nm Enclosure(s) c: cc: (Client Here) cc: (Local SSA Branch Here)

16200SWPacificHwy,Ste.H233*PortlandOR97224*5032456309office/5032962632*www.kplawllc.com*attorneys@kplawllc.com

file Claim 2

Case Analysis Form Name: __________________________________________________ DOB _________________ Theory: __________________________________________________________________________ __________________________________________________________________________ Med-Voc Rule__________ Issues: Listings ___________ Alleged Onset:______________ DLI:_____________

__________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

ATTORNEY'S RANKING OF IMPAIRMENTS 1. 2. 3. 4. 5. Date Last Worked: ____________ Age today: ________ 1. 2. 3. 4. 5.

ASSOCIATED SYMPTOMS

Age at onset: ________ * Enter C for customary, E for easiest job. Strength Level Skill Level DOT No. C/ E*

Past 15 years or 15 years before date last insured, if earlier. Dates Occupation

Unable to do easiest job because: ___________________________________________________________ Limited to: less than sedentary alt sit/stand sedentary light medium

Mental limitations: ________________________________ Highest Grade Completed: _______

Work skills: _________________________

Vocational Training: ______________________________________

Check here if abilities appear less than level of schooling would indicate.

Summary of Physical Residual Functional Capacity _________________________________ says that s/he can walk about _____ blocks before stopping. S/he can sit for about _____ minutes at one time and stand for about _____ minutes at one time. Out of an 8-hour working day, s/he says s/he can sit for a total of hours. hours and stand/walk for a total of

S/he needs to walk around approximately every _____ minutes for about _____ minutes. S/he needs a job that permits shifting positions at will.

Because of

muscle weakness chronic fatigue

pain/ paresthesias, numbness adverse effects of medication

_________________ _________________

s/he may need to take unscheduled breaks [ to lie down] during an 8-hour working day. S/he expects this to happen ______________________________; and s/he may need to rest ___________ minutes (on average) before returning to work. If s/he had a sedentary job, because of ___________________________ s/he says s/he would need to elevate his/her legs about _____% of the time during an 8-hour working day. S/he needs to elevate his/her legs about hip / heart ______ high. S/he needs a cane to walk because of imbalance insecurity weakness dizziness pain ________________________________________

S/he can occasionally lift and carry _____ lbs. and frequently lift and carry _____ lbs. S/he says that because of pain/ paresthesias muscle weakness limitation of motion motor loss sensory loss/ numbness swelling side effects of medication _______________________________________

s/he has significant limitations in reaching, handling, and fingering. S/he can use her/his left hand for grasping _____% of the time, fingering _____% of the time, reaching overhead _____% of the time, and reaching in front of body _____% of the time. S/he says that s/he can never rarely occasionally frequently S/he can use her/his right hand for grasping _____% of the time, fingering _____% of the time, and reaching overhead _____% of the time, and reaching in front of body _____% of the time.

twist, stoop (bend), crouch/ squat, climb ladders, and climb stairs.

S/he says that s/he can never rarely occasionally frequently

look down (sustained flexion of neck), turn head right or left, look up, and hold head in static position.

S/he says that s/he has the following environmental limitations: __________________________________________________________________________________ __________________________________________________________________________________

-2-

S/he says that her/his symptoms (often) (frequently) (constantly) are severe enough to interfere with attention and concentration so that s/he would be off task at work 5% / 10% / 15% / 20% / 25% or more / of the time. S/he says that as a result of his/her impairments s/he has a (moderate) (marked) (severe) limitation in dealing with work stress. Because of bad days, s/he says that if s/he had a full-time job s/he expects that s/he would miss work about/ more than _____ times a month. VISION

S/he says that s/he can never rarely occasionally frequently constantly

utilize near acuity, utilize far acuity, and utilize depth perception.

S/he is incapable of avoiding ordinary hazards in the workplace, such as boxes on the floor, doors ajar, approaching people or vehicles. S/he has difficulty walking up or down stairs because of his/her vision. S/he says s/he cannot work with small objects such as those involved in doing sedentary work. S/he can/ cannot work with large objects. Other: ____________________________________________________________________________ __________________________________________________________________________________

N O W 1. 2.

DOCTORS TO GET RFC OPINIONS FROM

TYPE OF RFC FORM 1. 2.

OTHER RECORDS THAT SSA MAY NOT HAVE OBTAINED

3.

3.

4.

4.

LONG TERM DISABILITY CARRIER Name: Address:

OTHER RECORDS NEEDED SS file from local office Work records - employer:________________ Vocational rehabilitation records L.T.D. carrier records School records Driving record Other:_________________________________ Other:_________________________________

-3-

Flag to work up for possible on-the-record decision. Impression: __________________

Request postponement of hearing scheduled for _________ with ALJ ______________

OTHER THINGS TO DO ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ THINGS OUR CLIENT WILL SEND US ______________________________________________________________________________________ ______________________________________________________________________________________ 1-25 2/04 175.1

-4-

Lisa R.J. Porter, Esq. Admitted in OR and WA Melissa N. Kenney, Esq. Admitted in MD Of Counsel: David B. Lowry, Esq. Admitted in OR and AZ

[DATE] [CLIENT NAME AND ADDRESS] RE: Your Social Security Claim Dear : We have filed an appeal on your behalf because we received a notice that you were denied benefits. We have to submit the enclosed form SSA-3441 with this appeal. The Social Security office will take no action until the enclosed form is returned to our office and forwarded to the property SSA office. If you have any questions, please call us immediately. PLEASE NOTE this needs to be done as soon as possible. We have enclosed a self-addressed stamped envelope for your use to return this form to us. Please do not return the instruction and privacy sheet. You may find it easier to list your prescription medications by going to your pharmacy and asking for a printout of your prescription history for the last 6 months. ***HELPFUL HINT: I encourage you to make a copy of this form before you return it to us so you can use it for an information reference in the future. You may have to complete this form again to updated your file. We have been told that Social Security will NOT move your claim forward without this completed form***** We may have to include a SSA-827 (if this form is needed it will be enclosed). You need to SIGN AND DATE. Please use DARK INK when completing the questionnaire. Please DO NOT use pencil. If you have any questions, dont hesitate to give us a call. Yours truly, Nanette L. Mitchell, Paralegal to KP Law LLC, Melissa N. Kenney and Lisa R. Porter, Attorneys /nm Enclosure(s)

Lisa R.J. Porter, Esq.

Admitted in OR and WA

Melissa N. Kenney, Esq.

Admitted in MD

Of Council: David B. Lowry

Admitted in OR and AZ

RE: Your Social Security Claim Dear : We are sending you forms to complete, sign and return to our office. If you are receiving this letter and packet, we have reason to believe that you are responsible and will return the materials as soon as possible. We are sure that this will be easier and less expensive than a visit to our office. This packet should include the following. If something is missing, please contact our office. Please use dark (Black or Dark Blue) ink when completing the forms. Please do NOT use pencil. FORM NEEDS SSA-1696 Appointment of Rep. (Signature where indicated) 2 "Fee Agreement" forms. (Signature where indicated) SSA-3288 Consent for Release... (Name; Date of Birth; SS#; Signature; Date) SSA-827 Authorization to Disclose (Signature, date) Authorizations for Release... (Initial ALL highlighted blanks; Sign; Do NOT date) Alternate Contact (Name of someone who knows how we can reach you in an emergency).

* * * * * *

Thank you for your time and attention to this matter. If you have any questions, please do not hesitate to contact this office. We will be happy to answer your questions so we do not have to return the forms to you for correction or completion. Please contact our office three (3) days after you return the documents back to our office. At that time, we will schedule you for an appointment with an attorney in our office. Finally, if you have received a denial, please send us copies of all denials that you have received. This can be very important to our course of action. Yours truly,

, Paralegal to Melissa Kenney and Lisa Porter, Attorneys /nm Enclosure(s)

16200 SW Pacific Hwy, Ste. H-233* Portland OR 97224 *503-245-6309 office / 503-296-2632 * www.kplaw-llc.com * attorneys@kplaw-llc.com

DISABILITY REPORT - APPEAL - Form SSA-3441-BK

READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM We will use the information that you give us on this form to update your disability report information for your appeal. We will use the form to update your disability information since you last completed a disability report. Please complete as much of the form as you can. If you need help, your interviewer will help you finish it. If you have an appointment for an interview by telephone, have the form ready to discuss with us when we call you. If you have an appointment for an interview in our office, bring the completed form with you or mail it ahead of time, if you were told to do so. If you have access to the Internet, you may access the Disability Report Form - Appeal instructions at http://www.ssa.gov/online/ssa-3441.html. If you are filling out the form for someone else, please provide information about him or her. When a question refers to "you," "your," or the "Disabled Person," it refers to the person who is applying for or has been entitled to disability benefits. HOW TO COMPLETE THIS FORM

Disability Report-Appeal SSA-3441-BK

Print or write clearly. DO OT LEAVE A SWERS BLA K. If you do not know the answers, or the answer
is "none" or "does not apply," please write: "don't know," or "none," or "does not apply." I SECTIO 3, PUT I FORMATIO O O LY O E DOCTOR/HMO/THERAPIST/OTHER/HOSPITAL/CLI IC I EACH SPACE. Each address should include a ZIP code. Each telephone number should include an area code. DO OT ASK A DOCTOR OR HOSPITAL TO COMPLETE THIS FORM. However, you can get help from other people, like a friend or family member. Be sure to explain an answer if the question asks for an explanation, or if you want to give additional information. If you need more space to answer any questions or want to tell us more about an answer, please use Section 10 - REMARKS on Page 7, and show the number of the question being answered. ABOUT YOUR MEDICAL RECORDS If you have any medical records or copies of prescriptions at home, send them to our office with your completed form or, if you are having an interview in our office, bring them and any medicine containers with you. If you need the records back, tell us and we will photocopy them and return them to you. YOU DO OT EED TO ASK DOCTORS OR HOSPITALS FOR A Y MEDICAL RECORDS THAT YOU DO OT ALREADY HAVE. With your permission, we will do that for you. The information we ask for on this form tells us to whom we should send a request for medical and other records. If you cannot remember the names and addresses of your medical sources, you may be able to get that information from the telephone book, medical bills, prescriptions, or prescription containers.

The Privacy Act

We are authorized to collect the information on this form under sections 205(a) and (b), 223(d), and 1631(e)(1) of the Social Security Act. We will use the information you provide on this form to make a decision on your claim or case. Your response to this request is voluntary. However, failure to provide all or part of the information could prevent us from making an accurate and timely decision on your claim or case. We rarely use the information you supply for any purpose other than for determining your living arrangements. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include but are not limited to the following: (1) to enable a third party or an agency to assist Social Security in establishing rights to Special Veterans Benefits; (2) to comply with Federal laws requiring the release of information from Social Security records (e.g., to the Department of Veterans Affairs); (3) to make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and (4) to facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social Security programs. We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these programs. Additional information regarding this form, routine uses of information, and our programs and systems, is available on-line at www.socialsecurity.gov or at any local Social Security office.

The Paperwork Reduction Act

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 control number. We estimate that it will take about 45 minutes to read the instructions, gather the facts, and answer the questions. SE D OR BRI G THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form. AFTER COMPLETI G THIS FORM, REMOVE THIS SHEET A D KEEP IT FOR YOUR RECORDS.

SOCIAL SECURITY ADMINISTRATION

Form Approved OMB No. 0960-0144

DISABILITY REPORT - APPEAL

For SSA Use Only Do not write in this box.

Related SSN Individual is filing:

Reconsideration

Number Holder Date of Last Disability Report

Request for ALJ Hearing

Request for Review by Federal Reconsideration for Disability Cessation Reviewing Official

SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON A. NAME (First, Middle Initial, Last) B. SOCIAL SECURITY NUMBER

daytime number where we can leave a message.)

C. DAYTIME TELEPHONE NUMBER (If you do not have a number where we can reach you, give us a ( ) Number

Your Number

Message Number

None

Area Code

D. Give the name of a friend or relative that we can contact (other than your doctors) who knows about your illnesses, injuries, or conditions and can help you with your claim or case.
NAME ADDRESS
(Number, Street, Apt. No.(If any), P.O. Box, or Rural Route)

RELATIONSHIP

City State
ZIP

( ) DAYTIME PHONE Area Code

Number

SECTION 2 - INFORMATION ABOUT YOUR ILLNESSES, INJURIES, OR CONDITIONS A. Has there been any change (for better or worse) in your illnesses, injuries, or conditions since you last completed a disability report? Yes No
If "Yes," please describe in detail:

Approximate date the changes occurred:

Month Day Year

B. Do you have any new physical or mental limitations as a result of your illnesses, injuries, or conditions since you last completed a disability report? Yes No
If "Yes," please describe in detail:

Approximate date the changes occurred:

Month Day Year

Form SSA-3441-BK (08-2010) ef (08-2010) Destroy Prior Editions

PAGE 1

C. Do you have any new illnesses, injuries, or conditions since you last completed a disability report? Yes No
If "Yes," please describe in detail:

Approximate date the changes occurred:

Month Day Year

If you need more space, use Section 10 - REMARKS. SECTION 3 - INFORMATION ABOUT YOUR MEDICAL RECORDS A. Since you last completed a disability report, have you seen or will you see a doctor/hospital/clinic or anyone else for the illnesses, injuries, or conditions that limit YES NO your ability to work? B. Since you last completed a disability report, have you seen or will you see a doctor/hospital/clinic or anyone else for emotional or mental problems that limit your YES NO ability to work? C. List other names you have used on your medical records.

If you answered "NO" to both A and B, go to Section 4 - MEDICATIONS.

Tell us who may have medical records or other information about your illnesses, injuries, or conditions since you last completed a disability report. D. List each DOCTOR/HMO/THERAPIST/OTHER. Include your next appointment.
1. NAME STREET ADDRESS FIRST VISIT DATES

CITY

STATE

ZIP

LAST VISIT

PHONE

Phone Number

PATIENT ID # (If known)

NEXT APPOINTMENT

Area Code

REASONS FOR VISITS

WHAT TREATMENT DID YOU RECEIVE?

Form SSA-3441-BK (08-2010) ef (08-2010)

PAGE 2

2. NAME STREET ADDRESS FIRST VISIT

DATES

CITY

STATE

ZIP

LAST VISIT

PHONE

Phone Number

PATIENT ID # (If known)

NEXT APPOINTMENT

Area Code

REASONS FOR VISITS

WHAT TREATMENT DID YOU RECEIVE?

If you need more space, use Section 10 - REMARKS. E. List each HOSPITAL/CLINIC. Include your next appointment.
HOSPITAL/CLINIC NAME TYPE OF VISIT INPATIENT STAYS
(Stayed at least overnight)

DATES
DATE IN DATE OUT

STREET ADDRESS
STATE ZIP

CITY

OUTPATIENT VISITS
(Sent home same day)

DATE FIRST VISIT

DATE LAST VISIT

PHONE

Phone Number

EMERGENCY ROOM VISITS

DATES OF VISITS

Area Code

Next appointment Reasons for visits

Your hospital/clinic number

What treatment did you receive?

What doctors do you see at this hospital/clinic on a regular basis?

If you need more space, use Section 10 - REMARKS.

Form SSA-3441-BK (08-2010) ef (08-2010)
PAGE 3

F. Since you last completed a disability report, does anyone else have medical records or information about your illnesses, injuries, or conditions (for example, Workers' Compensation, insurance companies, prisons, attorneys, or welfare agency), or are you YES NO scheduled to see anyone else?
If "YES," complete information below: NAME STREET ADDRESS FIRST VISIT DATES

CITY

STATE

ZIP

LAST VISIT

PHONE

Phone Number

NEXT APPOINTMENT

Area Code

CLAIM NUMBER (if any) REASONS FOR VISITS

If you need more space, use Section 10 - REMARKS. SECTION 4 - MEDICATIONS Are you currently taking any medications for your illnesses, injuries or conditions?
If "YES," please tell us the following: (Look at your medicine containers, if necessary.)

YES

NO

NAME OF MEDICINE

IF PRESCRIBED, GIVE NAME OF DOCTOR

REASON FOR MEDICINE

SIDE EFFECTS YOU HAVE

If you need more space, use Section 10 - REMARKS.

Form SSA-3441-BK (08-2010) ef (08-2010)
PAGE 4

SECTION 5 - TESTS Since you last completed a disability report, have you had any medical tests for illnesses, injuries, or conditions or do you have any such tests scheduled? YES NO
If "YES," please tell us the following: (Give approximate dates, if necessary.)

KIND OF TEST
EKG (HEART TEST) TREADMILL (EXERCISE TEST) CARDIAC CATHETERIZATION BIOPSY -- Name of body part HEARING TEST SPEECH/LANGUAGE TEST VISION TEST IQ TESTING EEG (BRAIN WAVE TEST) HIV TEST BLOOD TEST (NOT HIV) BREATHING TEST X-RAY -- Name of body part MRI/CT SCAN -- Name of body part

WHEN WAS/WILL TEST BE DONE? (Month, day, year)

WHERE DONE? (Name of Facility)

WHO SENT YOU FOR THIS TEST?

If you need more space, use Section 10 - REMARKS. SECTION 6 - UPDATED WORK INFORMATION Have you worked since you last completed a disability report?
If "YES," you will be asked to give details on a separate form.

YES

NO

SECTION 7 - INFORMATION ABOUT YOUR ACTIVITIES A. How do your illnesses, injuries, or conditions affect your ability to care for your personal needs?

Form SSA-3441-BK (08-2010) ef (08-2010)

PAGE 5

B.

What changes have occurred in your daily activities since you last completed a disability report?

If none, show "NONE."

If you need more space, use Section 10 - REMARKS. SECTION 8 - EDUCATION/TRAINING INFORMATION Have you completed any type of special job training, trade or vocational school since you last completed a disability report? YES NO
If "YES," describe what type:

Approximate date completed: SECTION 9 - VOCATIONAL REHABILITATION, EMPLOYMENT, OTHER SUPPORT SERVICES INFORMATION, OR INDIVIDUALIZED EDUCATION PROGRAM Since you last completed a disability report, have you participated, or are you participating in:

an individual work plan with an employment network under the Ticket to Work Program; an individualized plan for employment with a vocational rehabilitation agency or any other organization; a Plan to Achieve Self-Support; an individualized education program through an educational institution (if a student age 18-21); or any program providing vocational rehabilitation, employment services, or other support services to help you go to work? YES NO

If "YES," complete the following information: NAME OF ORGANIZATION OR SCHOOL NAME OF COUNSELOR OR INSTRUCTOR ADDRESS
(Number, Street, Apt. No.(if any), P.O. Box, or Rural Route)

City State ZIP

DAYTIME PHONE NUMBER

(
Area Code

Number

DATES SEEN TYPE OF SERVICES, TESTS, OR EVALUATIONS PERFORMED

Form SSA-3441-BK (08-2010) ef (08-2010)

TO

(IQ, vision, physicals, hearing, workshops, classes, etc.)

PAGE 6

SECTION 10 - REMARKS Use this section for any additional information you did not show in earlier parts of this form. When you are finished with this section (or if you don't have anything to add), be sure to go to the next page and complete the blocks there.

Form SSA-3441-BK (08-2010) ef (08-2010)

PAGE 7

SECTION 10 - REMARKS

Name of person completing this form if other than the disabled person (Please print)

Date Form Completed (Month, day, year)

E-Mail Address of person completing this form (optional)

If the person completing this form is other than the disabled person or the person identified in Section 1. Item D., please complete the following information. Relationship to Disabled Person Daytime Telephone Number

(
Address (Number and street) City

)
State

ZIP

Form SSA-3441-BK (08-2010) ef (08-2010)

PAGE 8

Lisa R.J. Porter, Esq. Admitted in OR and WA Melissa N. Kenney, Esq. Admitted in MD Of Counsel: David B. Lowry, Esq. Admitted in OR and AZ

DATE CLIENT NAME AND ADDRESS RE: Dear , Congratulations, we have a hearing scheduled for you on: DATE at TIME. To prepare we would like you to contact any doctors/hospitals/clinics that have been treating you and be sure to request those records as soon as possible. Your medical records are the cornerstone of your disability claim so you need to get them to us well in advance of your hearing. Please have them faxed, or put on CD to be brought in to us or just mail them to us. You will be receiving a letter asking you to acknowledge this hearing date and time. It is important that you return this as soon as possible. You do not need to send us a copy of this acknowledgement; it is a standard practice of ODAR. It will be important for you to bring at least one person with you to the hearing as a potential witness. You will need to have current identification to get into the building and to your hearing. Please BE EARLY as this security measure can take a few minutes. You will be meeting with your attorney at least 30 minutes BEFORE the hearing, so they can prepare you. The hearings are kept relatively casual as everyone that attends them is also applying for disability and they understand you may have special needs. The Administrative Law Judges (ALJs ) try to keep the hearings to no more than one hour in length. The Attorney will be calling you to discuss your hearing with you before your hearing. If you have a new address or phone number as contact, it is important you let us know that, so we can be in good communication. Thanking you in advance for your time and we look forward to a successful outcome. Yours Truly, Hearing Scheduled

Nanette L Mitchell
Nanette L. Mitchell, Paralegal for Melissa N. Kenney, Attorney and Lisa R. Porter, Attorney KP Law LLC /nm

16200 SW Pacific Hwy, Ste. H-233* Portland OR 97224 *503-245-6309 office /F: 503-296-2632 * www.kplaw-llc.com * attorneys@kplaw-llc.com

[THIS IS TAKEN DIRECTLY FROM JAMES PUBLISHINGS WEBSITE www.ssas.com AND IS FREE TO USE] Intake Action Sheet Name: ________________________ Date: __________________ [] Letter to Local Office:

[ ] New Application Letter [ ] Cover Letter (in a pending case) With: [ ] Request for Reconsideration [ ] Request for Hearing [ ] Disability ReportAppeal [ ] Signed Releases [ ] Appointment of Representative Form [ ] Attorney or Client Fee Agreement [ ] Direct Payment of Authorized Fees Form SSA-1695 [ ] cc to Office of Disability Adjudication and Review [ ] cc to Client With Fee Agreement [ ] cc to Disability Determination Bureau With Enclosures [ ] Re-Open Prior Application [ ] Request Local Hearing [ ] Appealing Onset Date Only [ ] Opening Letter to Client [ ] Thank You Letter to Referral Source [ ] Letter to Client With Diary: [ ] Seizure Diary [ ] Headache Diary [ ] MS Diary

[ ] Other: ____________________

[ ] Letter to Disability Determination Bureau: [ ] Request Medical CE [ ] Request Psych CE

Now

Send in 30 Days

[ ] Request State Agency RFCs (both physical and mental) [ ] Request State Agency Electronic Worksheet and/or Rationale for Denying Claim [ ] Supply Additional Medical Records a. b. c. [ ] Supply Photos [ ] Other: __________________ [ ] Letter to Local Office Requesting eDib File (CD) [ ] Letter to Office of Disability Adjudication and Review [ ] Request DISCO DIB Earnings Record [ ] National Directory New Hire, Wage and Unemployment Report for the Following Years: __________________________ [ ] Detailed Earning Report: _____________ to Present [ ] Other: [ ] Letter to Former Employer (__________________) Requesting Confirmation of Last Day of Work [ ] Letter to Former Employer Requesting Personnel File (specify portion or specific documents) [ ] Letter to Medical Providers Requesting Records: a. covering b. covering c. covering d. covering [ ] Letter to Vocational Rehabilitation Agency Requesting Copy of File [ ] Run Client Through Legal Database

Social Security Administration

Please read the instructions before completing this form. Name (Claimant) (Print or Type) Social Security Number Wage Earner (If Different) Part I I appoint this person, Social Security Number

Form Approved OMB No. 0960-0527

APPOINTMENT OF REPRESENTATIVE
Melissa N. Kenney, 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224
(Name and Address)

to act as my representative in connection with my claim(s) or asserted right(s) under: XTitle II (RSDI)

Title XVI X
(SSI)

Title XVIII (Medicare Coverage)

Title VIII (SVB)

This person may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s). X I authorize the Social Security Administration to release information about my pending claim(s) or asserted right(s) to designated associates who perform administrative duties (e.g. clerks), partners, and/or parties under contractual arrangements (e.g. copying services) for or with my representative. X I appoint, or I now have, more than one representative. My main representative is . Melissa N. Kenney
(Name of Principal Representative)

Signature (Claimant) Telephone Number (with Area Code) Part II

Address Fax Number (with Area Code) Date

ACCEPTANCE OF APPOINTMENT

I, Melissa N. Kenney , hereby accept the above appointment. I certify that I have not been suspended or prohibited from practice before the Social Security Administration; that I am not disqualified from representing the claimant as a current or former officer or employee of the United States; and that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to on the reverse side of the representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will notify the Social Security Administration. (Completion of Part III satisfies this requirement.) Check one: X I am an attorney. I am a non-attorney eligible for direct payment under SSA law. I am a non-attorney not eligible for direct payment. I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice as an attorney. Yes x No I am now or have previously been disqualified from participating in or appearing before a Federal program or agency. Yes x No I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge.

Signature (Representative) Telephone Number (with Area Code) (503)245-6309 Part III (Select an option, sign and date this section.)

Address
16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224

Fax Number (with Area Code) (503)245-6725

Date

FEE ARRANGEMENT

x Charging a fee and requesting direct payment of the fee from withheld past-due benefits.(SSA must authorize the fee unless a regulatory exception applies. Charging a fee but waiving direct payment of the fee from withheld past-due benefits --I do not qualify for or do not request direct payment. (SSA must authorize the fee unless a regulatory exception applies.) Waiving fees and expenses from the claimant and any auxiliary beneficiaries --By checking this block I certify that my fee will be paid by a third-party, and that the claimant and any auxiliary beneficiaries are free of all liability, directly or indirectly, in whole or in part, to pay any fee or expenses to me or anyone as a result of their claim(s) or asserted right(s). (SSA does not need to authorize the fee if a third-party entity or a government agency will pay from its funds the fee and any expenses for this appointment. Do not check this block if a third-party individual will pay the fee.) Waiving fees from any source --I am waiving my right to charge and collect any fee, under sections 206 and 1631(d)(2) of the Social Security Act. I release my client and any auxiliary beneficiaries from any obligations, contractual or otherwise, which may be owed to me for services provided in connection with their claim(s) or asserted right(s).

Signature (Representative)
Form SSA-1696-U4 (03-2011) ef (03-2011) Destroy Prior Editions

Date

TWO-TIERED FEE AGREEMENT - SOCIAL SECURITY DISABILITY / SSI

ATTORNEY FEE: I employ Lisa R. Porter and/or Melissa N. Kenney to represent me before the Social Security Administration (SSA) in my disability case. If I win at any administrative level through the first administrative law judge (ALJ) decision after the date of this agreement, I agree that the attorney fee will be the lesser of twenty-five percent (25%) of all past-due benefits awarded to the claimant and all auxiliary beneficiaries under this claim, or the dollar amount established pursuant to 42 U.S.C. 406(a)(2)(A), which is currently $6000, but may be increased from time to time by the Commissioner of Social Security. The fee level in effect when my claim is decided is the amount that will apply for my case. I understand that my attorney has the right to seek administrative review to increase the amount of the fee set under the preceding sentence of this agreement; but if that happens, my attorney will not ask for a fee of more than 25% of total back benefits awarded in my case. If the first ALJ decision after the date of this agreement is a denial and my attorney agrees to appeal and I win my case later, the fee will be twentyfive percent (25%) of all back benefits awarded in my case. If I receive both social security disability and SSI benefits, I understand that my total fee will not be more than 25% of all past-due benefits, or no more than the limit set by 42 U.S.C. 406(a)(2)(A), if the limit applies. I understand that if I do not win benefits, then the attorneys get no fee. SCOPE OF REPRESENTATION: I have employed my attorneys to represent me in my Social Security disability and/or SSI claim. I understand that my attorneys do not represent me in any other public or private claim related to my disability, or with any other government agency or any insurance company unless separate arrangements, including a separate written contract, have been made for representation on any other claim. PAYMENT OF ATTORNEYS FEE: I understand that SSA will hold out 25% of past-due benefits and pay my attorneys for their work on my case unless my attorneys waive withholding and direct payment. If the attorneys waive withholding and direct payment or if SSA fails to withhold attorney fees, I will pay my attorneys promptly from the back benefits I receive. I WILL PAY EXPENSES: In addition to fees, I agree to pay my attorneys for reasonable expenses that they pay in my case. These may include medical records and reports, photocopying, travel expenses, transcript preparation, and the like. I will get a bill for expenses that show how and when my attorneys spent the money. In a case in which I get benefits, I agree to pay my attorneys back for these expenses as soon as I get a check for back benefits. I agree to pay expenses whether we win or lose. USE OF SOCIAL SECURITY NUMBERS: I understand that in order to represent me my attorney(s) are often required to include my full, unredacted social security numbers on various documents in the course of exchanging information relative to my Social Security claim(s) including those filed with the Social Security Administration, and that these documents are sometimes filed through the mail. I further understand that while I do not have to consent to allow this practice, which, without my consent, may be a violation of Oregon law, as I also do not have to execute this agreement at all, I want my attorney(s) to be able to fully represent me on these matters. Being fully informed, I hereby give my complete and unreserved consent to such social security number disclosure by my attorney(s) whenever in their sole judgment it is required or desirable. I HAVE NOT BEEN PROMISED THAT I WILL WIN: My attorneys promised that they will do their best to help me. They did not promise me that I will win. I accept and approve this agreement: Date:__________________________

____________________________________ Lisa R. Porter, Esq.

_______________________________________ Signature of Claimant Name: SSN.______________________________

____________________________________ Melissa N. Kenney, Esq.

MEDICAL RECORDS AGREEMENT Medical providers, e.g., Doctors, hospitals, clinics, counseling agencies, mental and physical therapy agencies, all charge lawyers top dollar for copies of medical records and these high costs then get passed on to clients, including you. Their patients - you - are usually able to obtain copies of these records at lower cost or free. Therefore, as one of our clients, you agree as follows: 1. I will obtain, and send promptly to my lawyers, copies of all medical records I cause to be generated during the life of my case. 2. I will obtain, and send promptly to my lawyers, copies of all important diagnostic test results. These include blood chemistry work-ups; X-Rays; CAT scans; MRI scans; Pulmonary Function tests; sleep studies; anything that is a test done to help a medical provider understand what is or is not a problem for me. 3. I will obtain, and send promptly to my lawyers copies of all EMERGENCY ROOM records that I may cause to exist by virtue of requesting help at a Hospital Emergency room or a facility often called an Emergi-Center. I understand that Emergency Room records have to be ordered separately from other hospital records, as hospitals usually keep these records separately. 4. I will obtain, and send promptly to my lawyers, copies of any medical records that pre-date my application for Social Security Disability by one year or more, that will establish a diagnosis and outlook for medical conditions, including mental health, which continue to represent a more than minimal effect upon my ability to get around and do things, like work. For this purpose, work includes my past work, as well as other work Social Security might claim that I can do. Such work includes jobs where I would sit for at least 6 hours out of an 8 hour day; jobs where I would stand and/or walk for at least 6 hours out of an 8 hour day. It is never a good idea to tell a medical provider that a lawyer or a legal case of some kind is involved. If you do, they likely will tell you that you cannot have the records, your lawyer has to order them. This is done so that they can charge me top dollar. Keep this in mind. Because you will end up paying top dollar. Accepted by:_________________________ Lisa R. Porter, Esq. Signature:___________________________ Name: SSN: Date:

Medical Provider Contact Information

Your attorney requests you to obtain complete treatment records from all healthcare providers, physical and mental. It is essential that you provide contact information for all Providers. We cannot win your case without this information! Be complete! Name:______________________ Submit Contact Information For all Healthcare Providers: PROVIDER: Clinic Name: Street Address 1: Street Address 2: City/State : Zip Code : Doctor=s Name: PHYSICAL _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ MENTAL __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ SSN:_____________________

Clinic Name: Street Address 1: Street Address 2: City/State : Zip Code : Doctor=s Name:

_________________________ _________________________ _________________________ _________________________ _________________________ _________________________

__________________________ __________________________ __________________________ __________________________ __________________________ __________________________

Former Employer Contact Information Your attorney has requested that we obtain information from previous former employer(s). Please return this form with the following former employer information: Name:________________________ SSN:______________________

Submit contact information for the last _____ employer(s).

Employer: Street Address 1: Street Address 2: City/State: Zip Code: Phone: Supervisor:

_____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________

Employer: Street Address 1: Street Address 2: City/State: Zip Code: Phone: Supervisor:

_____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________

Upon receipt from you, we will request that an employer questionnaire be completed by the indicated contact(s).

AUTHORIZATION TO DISCLOSE INFORMATION TO KP Law LLC

REGARDING NAME:______________________ SSN: _______________BIRTHDATE:______________ I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange) OF WHAT: All my contact information. This includes specific permission to release: 1. All records and other information regarding my recent contact information including and not limited to: Information specifically to include any and all contact information maintained by the State in connection with the administration of any benefits program or any other records the State may have regarding my location, or which might lead to discerning my location. This authorization applies to physical or postal addresses, phone numbers, email addresses, and contact information via all private and public parties who may know how to locate me. FROM WHOM: The State of Oregon, and all of its employees, specifically including but not limited to the: Corrections Department Driver and Motor Vehicles (DMV) Education Department Employment Department Housing/Community Services Department Human Services Department Labor and Industries Bureau TO WHOM: KP Law LLC PURPOSE: SSI (Supplemental Security Income Title XVI) and DIB (Disability Insurance Benefits Claim Title II)

Please sign using Blue or Black Ink Only authorizing disclosure:

SIGNATURE:____________________________________________ Date________________

Lisa R.J. Porter, Esq.

Admitted in OR and WA

Melissa N. Kenney, Esq.

Admitted in MD

Of Council: David B. Lowry

Admitted in OR and AZ

The preparation of a Social Security Disability case requires the gathering of considerable information. ( ) ( ) ( ) ( ) ( ( ( ( ) ) ) ) Please obtain for me a printout from your pharmacy for all medicines. Please send me a list of ALL of your medical, physical therapy, counseling, etc. appointments for the past 24 months. If you have not done so, please furnish me the names, addresses and telephone numbers of all witnesses. Please send me a copy of your disabled parking permit, or a copy of an application signed by your Doctor. Please send me a copy of 30 days of blood sugar readings. Please send me a copy of your hearing test results. Please send me the name, address and claim number for your old Workers Compensation case. Please send me a copy of all letters you have received from Social Security denying your disability claim. This includes your current claim, as well as any earlier claims that were denied by the Social Security Administration.

Whenever you answer questions or fill out a questionnaire for SSA, neither exaggerate or minimize your condition. SSA will deny your claim easily if you tell them what you can do, or you do not explain that you have problems doing these things. You want them to see the answers that reflect what you cannot do and why, or what you do only with difficulty and why. Any SSA questionnaires you fill out should be returned to ME and NOT to SSA. That way, I can make a copy and if you have said something unwise, or which might confuse SSA, we can talk about it. Thank you for your cooperation in this matter. VERY IMPORTANT: What is the name, address and telephone number of some one who DOES NOT LIVE WITH YOU, but will ALWAYS know where your are?

Name: Address: City/State/Zip Telephone: Relationship:

AUTHORIZATION FOR RELEASE OF INFORMATION I authorize ____________________________________________________________________ to disclose a copy of the health information described below regarding the following: Name: _____________________ SSN:___________________________ DOB:__________________________ To: KP Law LLC Attorneys At Law

The undersigned hereby authorizes attorney, Melissa N. Kenney, Lisa Porter, or any representative thereof, to obtain information, for the purpose of obtaining Social Security Benefits. PLEASE INITIAL ALL THE SPACES BELOW _____ All Physician/Hospital/Clinic/Emergency/Urgent Care/Dental/Physical Therapy records (including lab, x-ray, diagnostic/consultative summaries), including protected records (if applicable) This authorization does not curtail the ability or inability to the condition of general healthcare upon its receipt. _____ Billing Statements _____ Workers Compensation Records

16200 SW Pacific Hwy, Suite H-280 Portland, OR 97224 (503) 245-6309 (503) 245-6725 Fax

PROTECTED OR SENSITIVE INFORMATION: I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer be will protected under federal law. I also understand that federal or state law may restrict redisclosure of HIV/AIDS information, mental health information, genetic information and drug/alcohol diagnosis.

I authorize the release of the following protected or sensitive information:

PLEASE INITIAL ALL THE SPACES BELOW _____ Drug/Alcohol diagnosis/treatment/or referral _____ Psychological and/or psychiatric treatment _____ Genetic testing information PLEASE INITIAL ALL THE SPACES BELOW ______ ______ ______ Adult & Family Services/Senior Disabled Services Records (Medical and Mental Health Treatment Records) _____ Any and all School records and transcripts including all counseling/psychological records ______ I specifically consent to the FAXing of my records. All FAXed material will contain a confidentiality statement, however, understand confidentiality at the receiving end cannot always be guaranteed. Police records Employment records Federal, state income records _____ _______ Sexually transmitted diseases _______ AIDS/HIV test results, including RELATED high-risk behaviors

You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care service is if the health care services are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure. You may revoke this authorization, please send a written statement to KP Law LLC at the above address and state that you are revoking this authorization. Unless revoked earlier, this consent will expire 180 days from the date of signing or shall remain in effect for the period reasonably needed to complete the request. This authorization is in compliance with HIPAA PHOTOCOPIES OF THIS AUTHORIZATION ARE VALID AND MAY BE USED IN LIE OF THE ORIGINAL

Clients Name (Please print)___________________________________________ Dated:______________ Clients Signature __________________________________________________

___________________________________________________________________ Parent or Guardians Signature ___________________________________________________________________ 9/09/2011 Forms/AUTHO If signed as parent or guardian, this authorization shall apply to the records of the above mentioned individual ___________________________________ Name of Parent or Guardian of Client

This is a true copy of the original authorization document. A true copy shall be deemed to be the same as the original thereof.

Signature of Staff Person

Social Security Administration Consent for Release of Information TO Social Security Administration
______________________ Name ___________ Date of Birth

Form Approved OMB No. 0960-0566

___________________________ Social Security Number

I authorize the Social Security Administration to release information or records about me to:
Melissa N. Kenney Lisa R. Porter Nanette L Mitchell Leta Sanders Rahma Abdulaziz 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224

___X____ ___X____ ___X____ ___X____ ___X____ ___X____ _______

Social Security Number Identifying information (includes date and place of birth parents names) Monthly Social Security benefit amount Information about benefits/payments I received ______________ to _________________ Information aobut my Medicare claim/coverage from _____________to ________________ (specify)____________________________________________________________________ Medical records Record(s) from my file (specify)___________________________________________________ _____________________________________________________________________________

I am the individual to whom the information/record applies or that persons parent (if a minor) or legal guardian. I declare under penalty of perjury that I have examined all of the information on this form and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.
Signature: _____________________________________________________________________________________ (show signature names and addresses of two people if signed by a mark) Date:_________________________________ Relationship: ______________________________________

Form SSA-3288 (3-2005) EF (3-2005)

LisaR.J.Porter,Esq.
AdmittedinORandWA

MelissaN.Kenney,Esq.
AdmittedinMD

OfCouncil:DavidB.Lowry
AdmittedinORandAZ

[DATE] CLIENTADDRESS RE:YourSocialSecurityClaim Dear, Wearesendingyoutheenclosedformstocomplete,signandreturntoouroffice.Pleasereturntheseformsassoonas possible.Pleaseuse(DarkBlackorDarkBlue)inkwhencompletingtheseforms.PleasedoNOTusepencil. EnclosedForms 1. ClaimantsRecentMedicalTreatmentFormHA4631 2. ClaimantsMedicationsFormHA4632 3. ClaimantsWorkBackgroundFormHA4633 4. AuthorizationtoDiscloseInformationtoSSAFormSSA827 Thankyouforyourtimeandattentiontothismatter.Ifyouhaveanyquestions,pleasedonothesitatetocontactour office. Yourstruly, NanetteL.Mitchell,Paralegalto KPLawLLC, MelissaKenneyandLisaPorter,Attorneys /nm Enclosure(s)
16200SWPacificHwy,Ste.H280*PortlandOR97224*5032456309office/5032962632*www.kplawllc.com*attorneys@kplawllc.com

Lisa R.J. Porter, Esq.

Admitted in OR and WA

Melissa N. Kenney, Esq.

Admitted in MD

Of Council: David B. Lowry

Admitted in OR and AZ

MEDICAL OPINION RE: ABILITY TO DO WORK RELATED ACTIVITIES (PHYSICAL) DATE TREATING PROVIDER NAME AND ADDRESS Re: CLIENT

Dear Medical Treating Provider: Please be advised that KP Law LLC represents your patient to help her or him obtain Social Security disability and/or S.S.I. Benefits. On behalf of our client, we request your cooperation by completing this questionnaire. This questionnaire is a significantly important source of evidence that may be used to determine a claimants inability to work eight hours a day, five days a week. Your information, with a minimum of time effort, will be most helpful, thank you. To determine your patients ability to do work related activities on a day-to-day basis in a regular work setting, please give us your opinion based on your examinations and past medical records of your client. Please consider how your patients physical capabilities are affected by her or his impairment(s) based on medical history, chronic findings, symptoms (including differing individual tolerances for pain and movement limitations), and the expected duration of any limitations that could interfere with work activities. Please consult your patient if there is any cost regarding completing this questionnaire, as the responsibility for the cost is the patients. Thank you for your time and attention to this important matter. If you have any questions, please feel free to contact our office at 503-245-6309. You may also fax this document to our fax at 503- 2456725. Sincerely yours, Gloria Cullins, Paralegal

For each activity shown below, indicate your (1) patients ability to perform the activity; and (2) identify the medical findings that support your opinion regarding the limitations (such as physical exam findings, MRIs, lab tests, history, symptoms, etc.). 1. Nature, frequency and length of contact with your patient: ______________________________________________________________________________ 2. Diagnoses:_____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. Prognosis:______________________________________________________________________ 4. List your patients symptoms:_____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 5. Identify clinical findings and objective signs:_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 6. Describe treatment and response to treatment, including side effects of medications, such as drowsiness, fatigue, dizziness, nausea, memory and concentration deficits, etc.:___________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 7. Have your patients impairments lasted or can they be expected to last at least 12 mos? Circle one: Yes No 8. Is it reasonable to expect that your patient would experience substantial difficulty with stamina, pain or fatigue if she or he worked full time, eight hours a day at a sedentary or light level of exertion? Circle one: Yes No 9. Would your patient likely need to work at a reduced work pace if employed full time, eight hours a day at a light or sedentary level of exertion? Circle one: Yes No 10. Would your patients health problems be made worse if she or he worked full time, eight hours a day at a light or sedentary level of exertion? Circle one: Yes No

11. Does your patient have (a) condition(s) that can be expected to result in death? Circle one: Yes No 12. Is your patient a malingerer? Circle one: Yes No

13. Do mental health issues contribute to the severity of your patients symptoms and functional limitations? Circle one: Yes No What are the psychological conditions affecting your patients physical condition? Circle the ones that apply: Depression Anxiety Personality disorder PTSD Other _____________________

14. Are your patients impairments and illness(es) consistent with causing the types of limitations she or he experiences? Circle one: Yes No 15. How often does your patients experience with symptoms severe enough to interfere with her or his attention and concentration? Circle one: Never Seldom Often Frequently Very Frequently

16. To what degree can your patient tolerate work stress? Circle one: Uncertain Incapable of even low stress jobs Capable of low stress jobs

Moderate work stress tolerable

Capable of high stress work

17. Please explain the reasons for your conclusion to the question above:_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

18. Does the patient have one or more impairments that requires her or him to: a. change position or posture more than once every two hours? Circle one: Yes No b. Affect her or his walking so much it interferes with the ability to independently initiate, sustain or complete normal activities of daily living? Circle one: Yes No c. Have sustained disturbance of gross and dexterous movements OR gait and station in two extremities? Circle one: Yes No 19. If you answer yes to any of the above, please state what medical findings support this:___________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 20. What is your patients maximum ability to stand and walk with normal breaks in an 8 hour workday: Circle one Less than 2 hrs About 2 hrs About 3 hrs About 4 hrs About 6 hrs No limit 21. What is your patients ability to sit with normal breaks in an 8 hour workday:Circle one Less than 2 hrs About 2 hrs About 3 hrs About 4 hrs About 6 hrs No limit 22. If your patient must periodically alternate sitting, standing or walking to relieve discomfort: a. How many minutes can your patient sit before changing position? _______________________________ b. How many minutes your patient stand before changing position? ___________________ c. How frequently in minutes must your patient walk around? ________________________________ d. How long in duration must your patient walk each time? __________________________ e. Does your patient need to shift at will from sitting or standing/walking?______________ f. Will you patient need to lie down at unpredictable intervals during a work shift? ________________________________________________________________________ g. If yes, how often do you think this will happen? ________________________________________________________________________ 23. What medical findings support the limitations described above?________________________________________________________________________ ______________________________________________________________________________

In an average 8 hour work day, rarely = 0% to 5%, occasionally= less than 2.75 hours, frequently=up to 5 hours. 24. What are your patients limitations in these functions: Frequently Occasionally Twist Stoop Crouch Climb stairs Climb ladders

Rarely

Never

25. Are the following physical functions affected by the impairment? Circle the ones that apply Reaching Handling Fingering Feeling Pushing/Pulling In an average 8 hour work day, rarely = 0% to 5%, occasionally= less than 2.75 hours, frequently=up to 5 hours. 26. How many pounds can your patient lift and carry in a competitive workplace: Frequently Occasionally Rarely Never Less than 10 10 lbs 20 lbs 50 lbs

27. How are these physical functions affected?_______________________________________________________________________ ______________________________________________________________________________ 28. What medical findings support this?__________________________________________________________________________ ______________________________________________________________________________ 29. What are your patients environmental restrictions to: No Avoid Avoid moderate Never restriction concentrated exposure exposure Extreme cold/heat Humidity Noise Fumes, odors, dust, gases, poor ventilation Hazards (machinery, heights)

30.

State any work-related activities which are affected by her or his impairment such as assistive devices for ambulation, need to elevate legs, limits on kneeling, or limitations related to a mental impairment and include the medical findings that support this:___________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

31. On the average, how often do you anticipate that your patients impairments or treatment would cause your patient to be absent from work? Circle one: Never Less than once a month Once a month Twice a month Three times a month Four or more times a month 32. If drug/alcohol abuse is present, is/was your patient self-medicating an underlying mental or emotional problem? Circle Yes or No. 33. If drug or alcohol abuse has been present, is/was this the primary/dominant cause of the patients disability? Circle Yes or No.

34. If yes, is this a situation where years of past drug or alcohol abuse have resulted in ongoing health problems that will now exist even though drug or alcohol abuse may have reduced/abated? Circle Yes or No. 35. If you are not an M.D., a Psy.D., a Ph.D, or a D.O., do you provide treatment to your patient in a clinic where a supervisory M.D., a Psy.D., a Ph.D, or D.O. is present? 36. Please provide the name of the supervisory M.D., a Psy.D., a Ph.D, or D.O. who supervises your treatment of your patient: _____________________________________________________________________________

Signature________________________________________________________________________ Printed/typed name________________________________________________________________ Address:________________________________________________________________________ _______________________________________________________________________________ Telephone:______________________________________________________________________ Date: __________________________________________________________________________

tAIry
l,r,r';,1 .rl,ill'r':',iri;lirrr

Lisa R.J. Porter, Esq. Admitted in OR and WA

Melissa N. Kenney, Esq.

Admitted in MD
Of Counsel: David B. Lowry, Esq.

Admitted in OR and AZ

MENTAL IMPATRMENT QUBSTIONNAIRE (RFC & LTSTTNGS)

DATE:
Providers Name:

RE:

DOB: Dear Provider:

Please be advised that KP Law LLC, ie Melissa Kenney and Lisa Porter represents the above claimant with respect to helping the above claimant obtain Social Security disability andlor S.S.I. benefits.

On behalf of our client we are requesting your cooperation in completing this questionnaire. This form is designed to provide important statutory information with a minimal time commitment on your part.
Please DO NOT send medical records unless specifically requested.

It is very important that you return this page along with the rest of the Questionnaire.
Please note that any cost be the responsibility of the patient. Please consult the patient regarding the cost completing the questionnaire, before costs are incurred.

will

of

Please answer the following questions conceming your patient's impairments.

1.
2.

Frequency and length contact:

of

DSM-W Multiaxial Evaluation: Axis fV: Axis

Axis I: Axis II:

Axis III:

V: Current CAF:
GAI
Past Year:

Highest

Typical GAF Past Year

Lowest GAF Past Year:

*503-245-6309 office 16200 SW Pacific Hwv, Ste. H-233* Portland OR97224

FAX: 503-530-8770

* wwuLd4 Llic.com

3.

Identifl, your patient's signs and symptoms associated with this diagnosis:
Intense and unstable interpersonal relationships and impulsive and damaging behavior

Anhedonia or pervasive loss of interest in almost all activities Appetite disturbance with weight change
Decreased energy

Disorientation to time and place

Perceptual or thinking disturbances

Thoughts of suicide

Hallucinations or deluslons

Blunt, flat or inappropriate affect

Feelings of guilVworthlessness

Impairment in impulse control

Poverty of content of speech Ceneralized persi stent anxiety Somatization unexplained by organic disturbance Mood disturbance

Difficulty thinking or concentrating Persistent non-organic disturbance of vision, speech, hearing, use of a limb, movement and its control, or
sensation Psychomotor agitation or retardation

Pathological dependence, passivity or agressivity Persistent disturbances of mood or affect Memory impairment - short, intermediate or long term Change in personality
Apprehensive expectation Paranoia or inappropriate suspiciousness Recurrent obsessions or compulsions which are a source of marked distress Seclusiveness or autistic thinking
Substance dependence

Hyperactivity Motor tension Catatonic or other grossly disorganized behavior Emotional lability Flight of ideas Maniac syndrome Deeply ingrained, maladaptive patterns of behavior Inflated self-esteem Unrealistic interpretation of physical signs or sensations associated with the preoccupation or belief that one has a serious disease or injury Loosening of associatrons Illogical thinking Vigilance and scanning Pathologically inappropriate suspiciousness or hostility Pressures ofspeech Easy distractability Autonomic hyperactivity Recurrent and intrusive recollection of a traumatic experience, which are a source of marked distress
Sleep disturbance

Oddities of thought, perception, speech or behavior

Decreased need for sleep

Incoherence

Emotional withdrawal or isolation Psychological or behavioral abnormalities associated with a dysfunction of the brain with a specific organic factorjudged to be etiologically related to the abnormal mental state and loss of previously acquired functional abilities Bipolar syndrome with a history of episodic periods manifested by the full symptomatic picture of both maniac and depressive syndromes (and currently characterized by either or both syndromes) Persistent irrational fear ofa specific object, activity, or situation which results in a compelling desire to avoid the dreaded obiect, activity or situation

Loss of intellectual ability of 15 IQ points or more Recurrent severe panic affacks manifested by a sudden unpredictability onset of intense apprehension, fear, terror and sense of impending doom occurring on the average of at least once a week

A history of multiple physical symptoms of several years duration beginning before age 30, that have caused and individual to take medicine frequently, see a physician often and alter life patterns significantly
Involvement in activities that have a high probability painful consequences which are not recognized

of

Other symptoms and remarks:

4.

Describe the clinicalfindings including results of mental status examination which demonstrate the severity of your patient's mental impairment and symptoms:

5. 6.

Is your patient a malingerer?

trYes nNo nYes

trNo

Are your patient's impairments reasonably consistent with the symptoms and functional limitations described in this evaluation?

lf

no, please explain:

7.

Treatment and response:

8.

a.

List of prescribed medications:

NAME OT'MEDICATION AND DOSAGE

DAILY AMOUNT TAKEN

b.

Describe any side effects of medications which may have implications for working. E.g., dizziness, drowsiness, fatigue, lethargy, stomach upset, etc.:

9.

Prognosis:

10.

Has your patient's impairment lasted or can it be expected to last at least twelve months?

DYes trNo
11.

Does the claimant have (a) condition(s)

of ill health that tend to degenerate

or deteriorate over

time?

trYes nNo
12. Is it reasonable to expect that claimant would experience substantial difficulty with stamin a, pain or fatigue if claimant was working full time, eight hours aday, at the light or sedentary levels of
exertion?

lYes 13.

trNo

Is it reasonable to expect that the claimant would need to work at a reduced work pace employed full time, eight hours a day, at the light or sedentary levels of exertion?

if

E
l3a

Yes

trNo

Is this patient's ability to work 8 hours a day,40 hours a week, and maintain a normal work pace:

o Very Good u l3b

Good

Fair

tr

Poor

n Very Poor

Please characterize your patient's experience

with stamina andlor fatigue:

910
No Prohlem
14.

Total Failure

Is it likely that one or more of the claimant's health problems would be made worse if the claimant was working full time, eight hours a day, at the light or sedentary levels of exertion?

IYes

trNo

15.

Does the claimant have (a) condition(s) of

ill

health that can be expected to result in death?

trYes
16. public he/she might encounter on the job?

trNo

If the claimant was working full time, 8 hours a day, forty hours a week, is it likely that the claimant would have substantial difficulty getting along appropriately with memblrs of the

trYes
t7. might encounter on the job?

trNo

If the claimant was working full time, 8 hours a day, forty hours a week, is it likely that the claimant would have substantial difficulty getting along with supervisors or co-workers he/she

lYes
1

nNo

Does the psychiatric condition exacerbate your patient's experience of pain or any other physical symptom?

8.

EYes nNo
If yes, please explain:

19.

Does your patient have a low I.Q. or reduced inteilectual functioning?

tr
Please explain (with reference to specific test results):

Yes

nNo

20.

on the average, how often do you anticipate that your patient's impairments or
treatment would cause your patient to be absent from work?

tr tr D
21.

Never month About twice a month

About once
a

tr

About three times a month About four times a month More than four times a month

o n

To determine your patient's ability to do work-related activities on a day-to-day basis in a regular work setting, please give us your opinion based on your examination of how your patient's mental/emotional capabilities are affected by the impairment(s). Consider thgmedical history, the chronicity of findings (or lack thereof), and the eipected duration of any workrelated limitations, but not your patient's age, sex or work experience.

DEFINITIONS OF RATING TERMS

No Limitations - The individual has no limitations in this area in a work setting.

Sliehtly Limited - The individual would experience s)4nptoms that would foreclose the ability to work successfully and effectively lYoto 9%o of the time in a work setting.

Mildlv Limited - The individual would experience symptoms that would foreclose the ability to
work successfully and effectively l}oh to
l9%o

of the time in

work setting.

Moderately Limited - The individual would experience s),rnptoms that would foreclose the ability to work successfully and effectively 20%to29Vo of the time in a work setting.

Markedly Limited - The individual would experience slmptoms that would foreclose the ability to work successfully and effectively 3O%to 39Yo of the time in a work setting.
Extremely Limited - The individual would experience s),mptoms that would foreclose the ability to work successfully and effectively 40% or more of the time in a work setting.
Using the above-listed DEFINITIONS OF RATING TERMS, please assess the degree of limitation the individual experiences in the categories of functioning set out below by placing a check mark or X in the corresponding boxes.

Mental Abilities and Aptitudes Needed to do

Unskilled Work A. Remember work-like procedures
B. Understand and remember very short and simple instructions
C. Carry out very short and simple instructions

No

Limitations

Slightly Limited

Mildly
Limited

Moderately

Limited

Markedly Limited

Extremely

Limited

D. Maintain attention for two hour segment

E. Maintain regular attendance and be punctual within customary, usually strict tolerances

F. Sustain an ordinary routine without special supervision G. Work in coordination with or proximity to others without being unduly distracted H. Make simple work-related decisions

I. Complete a normal workday and workweek

without intemrptions from psychologically
based symptoms J. Perform at a consistent pace without an

unreasonable number and length ofrest periods

K. Ask simple questions or request assistance L. Accept instructions and respond appropriately to criticism from supervisors

M. Get along with co-workers or peers without

unduly distracting them or exhibiting behavioral extremes N. Respond appropriately to changes in a routine work setting

O. Deal with normal work stress

P. Be aware of normal hazards and take appropriate precautions

22.

Explain limitations falling in the three most limited categories (identified by bold type) and include the medicaVclinical findings that support this assessment:

23.

Indicate to what degree the following functional limitations exist as a result of your patient's mental impairments.

less than extreme. A marked limitation may arise when several activities or functions are impaired or even when only one is impaired, so long as the degree of limitation is such as to seriously interfere with the ability to function independently, appropriately and effectively.
Functional Limitation
I

*Note: Marked means more than moderate, but

Degree of Limitation
None

Slight Slight

Moderate Moderate

Markedx Marked*

Extreme Exffeme

Difficulties in maintaining social

functioning
Defi ciencies of concentration, persistence or pace resulting in failure to complete tasks in a timely manner (in work settings or elsewhere) Episodes of deterioration of decompensation in work or work-like settings which cause the individual to

None

Never

Seldom

Often

Frequent

Constant

Never

Once or

Twice

Repeated (three or more times)

Continual

Continual

withdraw from that sifuation or to

experience exacerbation of signs and symptoms (which may include deterioration of adaptive behaviors)

24. 25.

Can your patient manage benefits in his or her own best

interest?

n Yes tr

No

Please state the approximate date from which claimant has continuously been unable to

work

26.

Please indicate

if

any of the following apply to your patient:

n Medically documented history of a chronic organic mental, schizophrenic, etc. or affective disorder of at least 2 years'duration that has caused more than a minimal limitation of ability to do any basic work activity, with symptoms or signs currently attenuated by medication or psychological support, and one of the following:

1.

Three episodes of decompensation within 12 months, each at least two weeks long.
disease process that has resulted in such marginal adjustment that even a minimal increase in mental d'emands or change in e the environment would be predicted to cause the individual to decompensate.

Z.

tr A residual

J.

TI current

history-of.lor more years' inability to function outside a highly supportive living arrangement with an indication of continuea'neea for such an arrangement.

4. 27.

tr

Complete inability to function independently outside the area of one's home.

If drugs or alcohol is present, is/was the claimant self-medicating an underlying 1bus9 mental or emotional problem?

trYes trNo
28.

(a) If drug or alcohol abuse has been present, is/ was this the primary, dominant cause of the claimant' s disability?

fl Yes tr
(Ul If yes, is there a situation where years of past drug or alcohol abuse have resulted
health problems that
abated?

No
in ongoing

will now exist even though drug or alcohol

abuse may have reduced or

nYes
29.

trNo

If you answered "No" to question #28,willthe underlying psychological problem improve with time or treatment?

trYes trNo
30.

If this person were to begin working 8 hours a day, forry hours a week, is it likely that the stresses or expectations of work would cause their Axis 5/GAF rating to decline? tr Yes D No E Don't Know
Has the claimant received Mental Health counseling services from a treatment team of counselors

31.

or therapists, however labeled, with a Doctoral level, M.D.; D.o.; ph.D.; psy.D.; Ed.D.; or other Doctoral Ievel person who has a Supervisory or Consultative role with the tieatment team?

nYes trNo

Signature:

Date:

Printed/Typed Name:
Address:

Signature of supervisory doctor (MD, Ph.D, Pys.D):

Thank you for your time and attention to this matter. If you have any questions, please feel free to contact this office.

c:file

Lisa R.J. Porter, Esq. Admitted in OR and WA Melissa N. Kenney, Esq. Admitted in MD Of Council: David B. Lowry, Esq. Admitted in OR and AZ

VIA FAX [DATE] Social Security Administration Local Branch Division St. RE: [CLAIMANT NAME] S.S.N.: Dear SSA: As you are aware, Melissa Kenney represents the interests of the above claimant in regarding to helping obtain Social Security Disability Benefits. Please find enclosed herein the following evidence in regard to this claim: SSA-1696 Appointment of Representative dated 7/31/12 (1) Two-Tiered Fee Agreement dated 7/31/12 (1) SSA-1695 Direct Payment of Authorized fees (1) KP Law LLC Fee Waiver Please redetermine this claim in light of the enclosed additional evidence POMS GN 03102.100 and/or GN 03103.010(B)(3). Thank you for your time and attention to this matter. Should you have any further questions, please do not hesitate to contact this office.
Yours truly, Nanette L. Mitchell, Paralegal KP Law LLC Melissa Kenney and Lisa Porter, Attorneys /nm Enclosure(s)
16200 SW Pacific Hwy, Ste. H-233* Portland OR 97224 *503-245-6309 office / 503-530-8770=Fax No. www.kplaw-llc.com *

Lisa R.J. Porter, Esq. Admitted in OR and WA Melissa N. Kenney, Esq. Admitted in MD Of Counsel: David B. Lowry, Esq. Admitted in OR and AZ Date: Social Security Administration Local Branch [NAME OF BRANCH]_ RE Claimant: S.S. N. : Dear SSA: Please be advised that KP Law LLC, Melissa N. Kenney and/or Lisa R. Porter attorneys, represents the interests of the above claimant in regard to helping obtain Social Security Disability Benefits. Please find enclosed herein the following documents in regard to this claim. SSA-1696 Appointment of Representative dated __ SSA-3288 Authorization to Release Information dated ______ SSA-1695 Identifying Information for Possible Direct Payment of Authorized Fees SSA-827 Authorization to Disclose Information Two-Tiered Fee Agreement dated ____ ________________ _________________

Please send us a copy of the Claimants earnings record, the Primary Insurance Amount and the Date Last Insured. PIA: $______________________ PFD:____________________DLI:______________________ Onset Date ___________________________ Please re-open any prior claims and award benefits. We also suggest that you obtain records from the following medical providers:

Thank you for your time and attention to this matter. If you have any questions, please feel free to contact this office. Sincerely,

Nanette L Mitchell
Nanette L Mitchell, Paralegal to Melissa N. Kenney and Lisa R. Porter, Attorneys /nm Enclosure(s)

16200 SW Pacific Hwy, Ste. H-233* Portland OR 97224 *503-245-6309 /FX No. 503-530-8770 attorneys@kplaw-llc.com

STANDARD FEE AGREEMENT - FEDERAL COURT SOCIAL SECURITY DISABILITY/SSI

ATTORNEYS FEE:I employ Lisa R. Porter, Attorneys at Law, to represent me before the Federal District Court and Circuit Court in my Social Security Disability case, Supplemental Security Income (SSI) case, or both. If I win in Federal Court, I agree that my attorneys fee will be authorized by the Court pursuant to the Equal Access to Justice Act (EAJA) and that this amount will be based upon the hours spent by the attorney on my case. This amount is paid by the Federal Government and not out of any SSD/SSI benefits that I may be awarded. I assign to my attorney, any right to EAJA fees that I may be awarded in my Federal Court case. I authorize my attorney to deposit EAJA fees in her own account for her own benefit. I understand that fees authorized by the Court for a successful appeal does not affect my agreement with Lisa R. Porter, for representation before the Social Security Administration. I understand that the attorneys fee in Federal Court depends on winning my case. If I do not win, then the attorneys get no fee. CONTINGENT FEDERAL COURT ATTORNEYS FEE I and my attorneys agree that if it is necessary to appeal this case to federal court, the attorneys fee for representation before the court is separate from and in addition to any fee for representation before the agency. The federal court attorneys fee shall be the GREATER of the following: 1) 25 (twenty-five)percent of the past-due benefits resulting from my claim or claims (which I understand may exceed $750.00 per hour), OR 2) The amount of any award ordered pursuant to the Equal Access to Justice Act (EAJA). EAJA fees are paid by an agency of the U.S. government-not out of the claimants past-due benefits. To the fullest extent permissible under law, I assign to my attorneys the right to receive any EAJA award(s) or check(s) in payment of award(s) directly in the attorneys names. My attorneys shall have the beneficial interest in the EAJA fee award. See 31 C.F.R. 285(e)(5)(2010. If the government issues checkes in my (the claimants) name for fees costs or expenses under an law which shifts to the government the responsibility for making such payments, I authorize my attorneys to sign and deposit such checks on my behalf, and immediately to take any amounts to which the attorneys are entitled under this contract. I authorize my attorneys to request that the court award beneficial interest in any costs, expenses, and/or EAJA fees to my attorneys, and that the government authority responsible for payment of such award(s) pay any and all amounts awarded directly to my attorneys in a check made payable to my attorneys and mailed to my attorneys address, or via deposit to my attorneys account. If any portion of a fee awarded in my case is taken by the federal government to pay any debt owed, I agree to immediately reimburse my attorneys for the amount of the fee taken in payment of my debt. 3) I understand and agree that my attorneys may receive EAJA fees for obtaining a court order remanding my case for further administrative proceedings, even if I am not ultimately found disabled after such further administrative proceedings. In order for
Page 1 of 2

5/23/11

my attorneys to be entitled to federal court fees paid out of my retroactive benefits, however, there must be a finding of disability (made either by the court or by the Social Security Administration after remand from the court) followed by an award of benefits to me and/or to other beneficiaries in association with my claim(s). If the Social Security Administration sends to my attorney a court fee authorized under 42 U.S.C. 406(b) which is larger than the fee my attorney is entitled to keep after offsetting any EAJA fee previously received by my attorney in connection with my claim, I instruct my attorney, on my behalf and as a convenience to me, to forward to my administrative attorney (if any) up to but not in excess of the amount of any then unpaid fee due (or pending agency approval) from me for representation before the agency. The total fee for both the Title II (SSD) and Title XVI (SSI) claims may not exceed the amount(s) stated above. I MAY CANCEL THIS AGREEMENT BY NOTIFYING Lisa R. Porter, IN WRITING BY THE END OF THE NEXT BUSINESS DAY AFTER I HAVE SIGNED IT. I have read this agree or had it explained to me before I signed it and have received a signed copy of it. I WILL PAY EXPENSES. In addition to the attorneys fee, I agree to pay my attorney for reasonable expenses that he pays in my case. These include long distance telephone calls, medical records and reports, photocopying, postage, travel expenses, and the like. I will get a bill for these expenses that shows how and when my attorney spent the money and I will pay these bill upon receipt. I agree to pay expenses whether we win or lose. I HAVE NOT BEEN PROMISED THAT I WILL WIN. My attorney promised that she will do their best to help me. She did not promise me that I will win. This agreement terminates at the option of Lisa R. Porter, if we lose in Federal Court. This agreement may be terminated by Ms. Porter, prior to completion of the Federal District Court case without cause. I accept and approve this agreement: __________________________ Date

_____________________________ Attorney Signature

__________________________ Claimants Signature Claimants Name: (printed or typed) Claimants SS No

Page 2 of 2

5/23/11

Lisa R.J. Porter, Esq.

Admitted in OR and WA

Melissa N. Kenney, Esq.

Admitted in MD

Of Council: David B. Lowry

Admitted in OR and AZ

DATE

CLIENT NAME AND ADDRESS RE: Your Social Security Claim Dear , Call our office immediately and ask to speak with the undersigned paralegal. Due to your claim being denied at the Office of Disability Adjudication and Review (ODAR), Lisa Porter would like to take your claim to the US District Court. Please look these documents over and sign where indicated. DO NOT DATE THEM. Please return all pages to our office by July 18, 2012 in the enclosed return envelope. Please answer the following four questions and return this letter with the enclosed forms: 1. Do you owe any back child support? _____NO _____YES: If yes, how much? ___________ 2. Are you in arrears for any back taxes? _____NO _____YES: If yes, how much? ___________ 3. Are you in default on any student loans? _____NO _____YES: If yes, how much? ___________ 4. Are you in default on any Small Business Administration loans? _____NO _____YES: If yes, how much? ___________

List below all names and aliases you have gone by in the past, including maiden name:

16200 SW Pacific Hwy, Ste. H-280* Portland OR 97224 *503-245-6309 office / 503-530-8770 * attorneys@kplaw-llc.com

_________________________________________________________________________ _________________________________________________________________________ Enclosed, please find five documents: The Complaint: Please look it over and sign the last page. DO NOT DATE IT. The Standard Fee Agreement: Please fill in the date, your signature, print your name and enter your social security number in the blanks provided. The Application to Proceed In Forma Pauperis: which if approved, will allow us to file your case in US District Court without you needing to pay the $350.00 fee. This questionnaire will be used by the court to determine your ability or inability to pay associated fees. Fill in the form, but DO NOT SIGN OR DATE IT. You must take it to a Notary Public and sign it in front of that person. You can typically find a Notary at a bank. Limited Power of Attorney: This must be signed as witnessed by two persons in front of a Notary Public. The Notary Public AND the two witnesses are absolutely required in order for your attorney Lisa R. Porter to be paid for her work on your case in Federal Court. Without this, he will not be taking your case to Federal Court. FMS-13 Authorization for Release of Information: Sign and date on the yellow highlighted lines.

Please return all pages to our office promptly in the enclosed return envelope.

Yours truly,

Nanette L Mitchell
Nanette L Mitchell, Paralegal to Lisa R. Porter, Esq. Enclosure(s)

16200 SW Pacific Hwy, Ste. H-280* Portland OR 97224 *503-245-6309 office / 503-530-8770 * attorneys@kplaw-llc.com

Information Required to Perform a Step-Four Analysis

[from James Publishing website www.ssas.com] After interviewing a claimant, and after reviewing the disability claim file and contacting third party witnesses such as co-workers, employers, and family members as necessary, a claimants representative will have determined the nature of the claimants past work activity in sufficient detail to list the following characteristics of each past relevant job the claimant has performed:

Client Name 1 2 3 4 5 6 7

8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Employer The job title as performed Date the job began Date the job ended Reason(s) the job ended Job duties as performed Function-by-function physical & mental (exertional and nonexertional) demands required to carry out the job duties as performed (worker trait factors) Environmental conditions in which the job was performed Wages/Self-employment income (by month, if possible, and as necessary to make an SGA determination) Impairment-related work expenses Employer or other subsidies Special circumstances, if any, under which the job was performed Machines used by the worker Tools used by the worker Equipment used by the worker Work Aids used by the worker Work processes carried out Work setting Industry Materials used by the worker Products made Subject matter dealt with Services rendered Skill level (SVP) as performed DOT job title and 9-digit occupational classification number DOT physical demand classification DOT skill level classification (SVP) DOT Reasoning (R), Mathematical (M), and Language (L) levels GOE code Significant SCO function-by-function worker trait factors as generally performed

Armed with this information, a direct function-by-function comparison of the claimants RFC with the functional demands of past relevant work resolves the step-four issue. If the step-four determination favors the claimant, the foregoing information will then be required to make the step-five determination, including a determination of whether the claimant has acquired work skills which may be transferred to other jobs within the claimants residual functional capacity.