Complaint (Social Security)

(Rev. 6/04) NOTICE TO COUNSEL: Service of Process must be in accordance with Fed. R. Civ. P. 4(i) and 20 C.F.R. Part 423. IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF DELAWARE (Plaintiff) V. Civil Action No. (Commissioner, Social Security Administration) (Defendant) COMPLAINT 1. The plaintiff, whose Social Security Account Number ends in the last four digits ***-**- __ __ __ __, and who is a resident of , , seeks (City) (State, zip code) judicial review pursuant to 42 U.S.C. 405(g) of an adverse decision of the defendant which has become final and bearsthe following caption: In the case of Claim for Claimant ***-**- _ _ _ _ (last four digits of Social Security No.) Wage Earner 2. Plaintiff has exhausted administrative remedies. WHEREFORE, plaintiff seeks a judgement for such relief as may be proper including costs and attorneys fees. ___________________________________ Signature Attorney for Plaintiff (City) (State) (Zip) Dated: (Area code) Telephone No.