Social Security Complaint For Judicial Review Of Decision By Commissioner

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 UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA __________________________________, ) ) Plaintiff, ) ) v. ) ) ___________________________________, ) ) Commissioner of Social Security. ) Defendant. ) ____________________________________) Facsimile Number Name of Attorney for Plaintiff/Name of Plaintiff (if pro se) ____________________________________ Address ____________________________________ Telephone Number ____________________________________ State Bar Number of Attorney Case No. ___________________________ COMPLAINT FOR JUDICIAL REVIEW OF DECISION OF COMMISSIONER OF SOCIAL SECURITY (Administrative Procedure Act Case) The above-named plaintiff makes the following representations to this court for the purpose of obtaining judicial review of a decision of the defendant adverse to the plaintiff: 1. The plaintiff is a resident of __________________________________, City State _____________________________________. 2. The plaintiff complains of a decision which adversely affect the plaintiff in whole or in part. The decision has become the final decision of the Commissioner for purpose of judicial review and bears the following caption: /// /// /// COMPLAINT -1- American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 In the case of: _____________________________ Claimant Claim for: ____________________________________ Type of Benefit _____________________________ 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 DATE: _____________________________ Wage Earner (Leave blank if same as above) ____________________________________ Last Four Digits of Social Security Number 3. The plaintiff has exhausted administrative remedies in this matter and this court has jurisdiction pursuant to Title 42, U.S.C. §405(g). WHEREFORE, the plaintiff seeks judicial review by this court and the entry of judgment for such relief as may be proper, including costs. ____________________________________ Signature of Attorney or Plaintiff Appearing Pro Se COMPLAINT -2- American LegalNet, Inc. www.FormsWorkFlow.com