Free Complaint for Appealing Denial of Social Security Benefits - Maryland

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND _____________________________ _____________________________ _____________________________ vs. COMMISSIONER, SOCIAL SECURITY : : : : : CIVIL ACTION NO. _______________

COMPLAINT l. Plaintiff is a resident of ________________________________________________. (Provide your City or County and State of residence) 2. Plaintiff complains of a decision against him/her bearing the following caption: IN THE CASE OF: _____________________________ (Claimant) _____________________________ (Wage Earner if Different from Claimant) 3. 4. The date of the final decision by the Secretary against plaintiff is ______________. Plaintiff claims that the final decision of the Secretary is erroneous as a matter of CLAIM FOR: ____________________________ (Type of benefits)

fact and as a matter of law. WHEREFORE plaintiff seeks judicial review by this Court pursuant to 42 U.S.C. Section 405(g), and entry of judgment for such relief as may be proper, including costs.

_____________ (Date)

________________________________________________ (Signature) ________________________________________________ ________________________________________________ ________________________________________________ (Printed name, address, and phone number of Plaintiff)

Complaint: Denial of Social Security Benefits (Rev. 7/21/2006)

CONFIDENTIAL INFORMATION
THIS DOCUMENT MUST BE SERVED ON THE GOVERNMENT ALONG WITH THE SUMMONS AND COMPLAINT. IT IS NOT TO BE FILED WITH THE COURT. IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND _____________________________ vs. COMMISSIONER, SOCIAL SECURITY : : : CIVIL ACTION NO. _______________

STATEMENT OF SOCIAL SECURITY NUMBER

Social Security Number of Claimant:

Social Security Number of Worker (if different than claimant):

_____________ (Date)

________________________________________________ (Signature) ________________________________________________ ________________________________________________ ________________________________________________ (Printed name, address, and phone number of Plaintiff)

Complaint: Denial of Social Security Benefits (Rev. 7/21/2006)