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Man Services 600 E Boulevard Ave, Dept. 325 Bismarck, ND 58505 Fax: (701) 328-1544 IDENTIFICATION Name of Claimant or Beneficiary Name of Wage Earner (If other than Claimant or Beneficiary) Blind Not Blind Claimant or Beneficiary is Receiving: Social Security Disability Insurance (SSDI) Benefits Both SSDI and SSI Disability Benefits Supplemental Security Income (SSI) Disability Benefits Neither SSDI or SSI Disability Benefits PART I - TO BE COMPLETED BY THE DEPARTMENT OF HUMAN SERVICES.

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