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PHYSICAL RESIDUAL FUNCTIONAL CAPACITY …
Form SSA-4734BK (1-89)1(Formerly SSA-4734-U8 Use prior editions)Form Approved OMB RESIDUAL FUNCTIONAL CAPACITY ASSESSMENTC laimant:SSN:000-00-0000 Number Holder(If CDB Claim):Primary Diagnosis:RFC assessment Is For:Secondary Diagnosis: Current EvaluationOther Alleged Impairments: Date Last Insured: Date 12 Months After Onset: Other(Specify):PRIVACY ACT/PAPERWORK ACT NOTICE: The information requested on this form is authorized by Section 223 and Section 1633 ofthe Social Security Act. The information provided will be used in making a decision on this claim. Failure to complete this form may resultin a delay in processing the claim Information furnished on this form may be disclosed by the Social Security Administration to anotherperson or governmental agency on]y with respect to Social Security progrants and to comply with federal laws S requiring the exchange ofinformation between Social Security and other Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance w
Form SSA-4734BK (1-89) 1 (Formerly SSA-4734-U8 Use prior editions) Form Approved OMB NO.0960-0431 PHYSICAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT
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