ARIZONA DEPARTMENT OF ECONOMIC SECURITYTUCSON DISABILITY DETERMINATION SERVICE

PO BOX 30731SALT LAKE CITY UT 84130-9836(520) 790-2580/1-800-362-6368

IRQID:L00003CQNE000 SITE:V16 DR:SSSN:********* DOCTYPE:5020 RF:D CS:2efl

Serial: 20091230400363

December 30, 2009JAMES ALBERT LOTT7640 S POWER RDAPARTMENT 2164GILBERT AZ 85297

We refer to our previous communications with you in connection with your eligibility orcontinuing eligibility for disability benefits under the provisions of the Social Security Act.

Upon review of the evidence in your file, we requested your assistance in order to evaluate yourcondition.

It was for this reason that we sent you the questionnaire and requested that it be completed andreturned to us. This information is necessary in order to make a proper decision on your claim.However, we still have not received the completed questionnaire.

Since we are compelled to process claims on a timely basis, we are writing to inform you that wecan wait no longer than 10 days from the date of this letter for the above information. At thattime, a decision may be made on your claim based on the information already in file. If you arecurrently receiving benefits, this may result in your benefits being stopped.

Esta carta se refiere a su reclame de beneficios bajo el Seguro Social o el Sistema de Cuidado aLargo Plazo en Arizona (ALTCS). Si no habla o lee ingles, favor de pedir ayuda de la oficinalocal de Seguro Social.

C. HERNANDEZ, Ext. 3247Disability ExaminerDisability Determination Service

Enc. SSA3373

ENC: Self Addressed Stamped EnvelopeD8100/her309/12/09/2009/21//N

CASE NUMBER: 1025292

SOCIAL SECURITY ADMINISTRATION Form Approved OBM No. 0960-0681

FUNCTION REPORT - ADULTHow your illnesses, injuries, or conditions limit your activities

For SSA Use OnlyDo not write in this box

IRQID:L0M03CQNE000 SITE:V16 DR:SSSN:********* DOCTYPE:5020 RF:D CS:2efl

SECTION A - GENERAL INFORMATION

1. NAME OF DISABLED PERSON (Last, Middle, First)LOTT, JAMES

2. SOCIAL SECURITY NUMBERSSN: 601-86-2480 Case Number: 1025292

3. DATE (Month, Day, Year)

4. YOUR DAYTIME TELEPHONE NUMBER (If there is no telephone number where you can be reached, pleasegive us a daytime number where we can leave a message for you.)

\/ Your Number _ Message Number _None

Area code Phone Number

5. a. Where do you live? (Check One)

House y Apartment _ Boarding House _ Nursing Home

_ Shelter _ Group Home _ Other (What)

b. With whom do you live? (Check one.)

Alone _^With Family _ With Friends

Other (Describe relationship)

SECTION B - INFORMATION ABOUT DAILY ACTIVITIES

6. Describe what you do from the time you wake up until going to bed..

*OA f.|

'[ir V A*.

c.i.1 \\flfitr tm^Form SSA-3373-BK (9-2004) ef (09-2004)

7. Do you take care of anyone else such as a wife/husband, children, grandchildren, V_ Yes _ Noparents, friend, other?

If "Yes," for whom do you care, and what do you do for them? EM-4 >- &H- Id/^A . i-"vJ

8. Do you take care of pets or other animals? _ Yes _i/No

AcHIf "YES," what do you do for them? (£>&^> Ac

9. Does anyone help you care for other people or animals? * Yes _ No

ftp riIf "YES," who helps, and what do they do to help? j\ft£ &*{ <3

>y TU ^

10. What were you able to do before your illnesses, injuries, or conditions that you can't do now?

11. Do the illnesses, injuries, or conditions affect your sleep? i/_ Yes _ No

If "YES," how?

12. PERSONAL CARE (Check here _ if NO PROBLEM with personal care.)

a. Explain how your illnesses, injuries, or conditions affect your ability to:

Dress - He c*uS JC A? rtof ggf ci S&tC . o/ UJ /" Mfflf<rSSAd*^S, ^

Bathe jToM ^P^KA*! Atm ^

A L.,f ^ (rtAq VCare for hair

Shave J h^^ | S/V^Cd

Feed self . ^g. A. AJC.

Use the toilet N/? <

Other?

Form SSA-3373-BK (9-2004) ef (09-2004) Page 2

j/ Yb. Do you need any special reminders to take care of personal j Yes _ Noneeds and grooming?

If "YES," what types of help or reminders are needed? J- h*vt <V*n JjV^S S<P'/- D

p

c. Do you need help or reminders taking medicine? _^_ Yes _ No

If "YES," what kind of help do you need? .1 />*>£ ff*?**bf<^ £ £ /

<*™.<\ ^g 5 /r*

13. MEALS

a. Do you prepare your own meals? v Yes _ No

If "YES," what kind of food do you prepare? (For example, sandwiches, frozen dinmrs, or completemeals with several courses.) J^uSt^Uu fW(t>t<.) /^<,/C Qitect. t//> ^ f ' & t

How often do you prepare food or meals? (For example, daily, weekly, monthly.)

How long does it take you?

Any changes in cooking habits since the illness, injuries, or conditions began?

fgH (fork S

b. If "No," explain why you cannot or do not prepare meals. ®Q AD[ ^^Pf M

14. HOUSE AND YARD WORKa. List household chores, both indoors and outdoors, that you are able to do. (For example, cleaning,

laundry, household repairs, ironing, mowing, etc.) Ci<?*»i.w ,

b. How much time does it take you, and how often do you do each of these things?

.jf' xc. Do you need help or encouragement doing these things? \/Yes __ No

If "YES," what help is needed? X -/\ff^ fttM^nf^ ^ nff(

Forms SSA-3373-BK (9-2004) ef (09-2004)

d. If you don't do house or yard work, explain why not.

15. GETTING AROUNDa. How often do you go outside?

\\

L it /» . Pfg**&g n^ .PEW./ >f IK >/£ fC)

If you don't go outside at all, explain why not.

b. When going out, how do you travel? (Check all that apply.)

V Walk Drive a car Ride in a car

Use public transportation Other (Explain)

c. When going out, can you go out alone?

If "NO," explain why you can't go out alone. Jl

Ride a bicycle

Yes

/ ')/•/,

"5d. Do you drive?

TU. f 4If you don't drive, explain why not. —I T iS on<^e\7£ I® Of* '

Yes ^No

16. SHOPPING

a. If you do any shopping, do you shop: (Check all that apply)

Stores _ By phone _ By mail

b. Describe what you shop for.

lor

K By computer

5v f C»i /.^<g

c. How often do you shop and how long doesxit take?

d

t

17. MONEY

a. Are you able to:

Pay bills

Count change

V_Yes

j/Yes

No

No

Explain all "NO" answers.

Handle a savings account _ Yes

Use a checkbook/money orders y^Yes _ No

frfc AAl'>£?

Form SSA-3373-BK (9-2004) ef (09-2004) page 4

b. Has your ability to handle money changed since the illness, _ Yes _injuries, or conditions began?

If "YES," explain how the ability to handle money has changed. no^S /1/Ty

18. HOBBIES AND INTEREST

a. What are youjf hqbbies and interests? (For example^ reading, watching TV, sewing, playingsports, etc.

b. How often and how well do you do these things? Wff/\ .1 A(V\ &•[&('}r

c. Describe any changes in these activities since the illness, injuries or conditions began.

~t fto loffy/ g j /> jp <Wo gg'/.'wlv^ . of Set

19. SOCIAL ACTIVITIES

a. Do you spend time with others? (In person, on the phone, on the computer, etc.) y Yes _ No

If "YES," describe the kinds of things you do with others. .Sfteftfl.V't <OiT

J- ^«-t.c [?y. A f j u ' P ^L .

How often do you do these things? )/ ftuxgcfc dr /4Si^/

b. List the places you go on a regular basis. (For example, church, community center, sports events,social groups, etc.) P<.ff\ iJ/l/>.Mfft\. _ f\p bjlvt£

Do you need to be reminded to go places? _L/.Yes _ No

How often do you go and how much do you take part? J- {^^rgn r£>

Do you need someone to accompany you? y/Yes __ No

Form SSA-3373-BK (9-2004) ef (09-2004) Page5

h. How well do youget along with authority figures? (For example, police, bosses, landlords orteachers) fopST/^ <_<.>(? If \f ^ **?r&'' \ t h fte, fa-± $&\<S> . _

'

i. Have you ever been fired or laid off from ajob because of problems getting _ Yes (/Hoalong with other people?

If "YES," please explain.

/-

(\<g)^\ /Vm 0

If "YES," please give name of employer. f

j 4\j. How well do you handle stress? j!\fel pjdl > ^\1t^ 6

QK,\\f, c*\l3LA$ <^s .^ *

k. How well do you handle changes in routine? A<5/ ^g'l JT^O/ £<*A«fAiV|C l'/1

^o ra

1. Have you noticed any unusual behavior or fears? _fc/Yes _ No

If "YES," please explain. JT fty/if Quef^ ^3 Afth.,4 &{

21. Do you use any of the following? (Check all that apply.)

Crutches Cane Hearing Aid

Walker Brace/Splint j/Glasses/Contact Lenses

Wheelchair Artificial Limb _ Artificial Voice Box

_ Other (Explain)

Which of these were prescribed by a doctor? _ "l*1^

When was it prescribed? t*£i

AH w N!<When do you need to use these aids? /1\\ ]pC J\>

Form SSA-3373-BK (9-2004) ef (09-2004) Page 7

SECTION D - REMARKS

Use this section for any added information you did not show in earlier parts of this form. When youare done with this section (or if you didn't have anything to add), be sure to complete the fields atthe bottom of this page.

Name of person completing this form (Please print)

1 / Hiy *>vv^S L £> V J

Date (month, day, year)

Address (Number and Street)

7 6*C) 5,

Email address (optional)

City State Zip Code

Form SSA-3373-BK (9-2004) ef (09-2004)