UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT
SOCIAL SECURITY COMPLAINT STATISTICAL INFORMATION SHEET This document is a statistical information sheet which is not docketed as part of your complaint. This document is required and must be completed and served on the United States Attorney's Office as part of the packet included with your complaint.
(Name of Plaintiff, typed or printed)
Case No. (Supplied by court when complaint filed)
(Social Security Number)
City, State, Zip Code
Email address if available
Signature of Plaintiff