Disability Information Current Monthly Rate: Potential Monthly Rate: Difference: Disability Income Over Time Time Period Current Potential Difference 1 Month 6 Months 1 Year 5 Years 10 Years Back Pay Details Rating Information: Current Rating Select 10 20 30 40 50 60 70 80 90 100 Potential Rating Select 10 20 30 40 50 60 70 80 90 100 Marital Information: Marital Status Select Single Married Does Your Spouse Need Aid & Assistance? Yes No How Many Dependent Children? Under the Age of 18 Select 1 2 3 4 5 6 7 8 9 None Between the Ages of 18 to 24 1 2 3 4 5 6 7 8 9 None Number of Dependent Parents Select 1 2 None Back Pay Information (Months) Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18