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UNITED STATES DISTRICT COURT EASTERN DISTRICT OF LOUISIANA
CIVIL ACTION

Plaintiff
versus

Commissioner of the Department of Health and Human Services-Defendant
COMPLAINT The above-named plaintiff makes the following representation 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)

and has a Social Security number ending in the last four digits ***-

**-

.

2. The plaintiff complains of a decision which adversely affects the plaintiff in whole or in part. The decision has become the final decision of the Commissioner for purposes of judicial review and bears the following caption:

In the case of (Claimant) (Wage Earner)

Claim for

***- **-

(last four digits of Social Security No.)

3. The plaintiff has exhausted administrative remedies in this matter and this court has jurisdiction for judicial review pursuant to 42 U.S.C. 405 (g).

WHEREFORE plaintiff seeks judicial review by this court and the entry of a judgment for such relief as may be proper, including costs. Date Signature Printed Name 04/2004 Street Address City, State, Zip Code Telephone Number