Free Social Security Complaint - Alaska

Name

Address Telephone number

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF ALASKA

,
(Full name of plaintiff)

Case No. Plaintiff, vs. MICHAEL J. ASTRUE, Commissioner of Social Security, Defendant. SOCIAL SECURITY COMPLAINT
(To be supplied by Court)

Plaintiff,
(Plaintiff's full name) (State)

, a resident of
(City)

,

, makes the following representations to this Court for the purpose of obtaining judicial review of a decision adverse to the plaintiff:

1.

Plaintiff complains of a decision which adversely effects him/her in whole or in part. The decision, dated , has become

the final decision of the Commissioner of Social Security for the purpose of judicial review, and bears the following caption:

PS06 (2/07)

1

Soc. Sec. Complaint

In the Case Of
(Claimant) (Wage Earner)

Claim For

(Social Security Number)

2.

Plaintiff alleges that the final decision of the Commissioner is erroneous as a matter of law and regulation for the following reason(s) (for example, lack of procedural due process, lack of substantial evidence, etc.):

3.

Plaintiff has exhausted administrative remedies in this matter, and the Court has jurisdiction for judicial review under 42 U.S.C. § 405(g).

4.

Plaintiff has attached a true and correct copy of the final decision of the Commissioner of Social Security.

WHEREFORE, plaintiff seeks judicial review by the Court and the entry of judgment for such relief as may be proper, including attorney's fees and costs.

I,

, declare under penalty of perjury, that I have

reviewed the above complaint, and that the information contained in this complaint is true and correct.

DATE:
(Signature of Plaintiff)
PS06 (2/07)

2

Soc. Sec. Complaint