Free Social Security Complaint Form (Southern Division) - Michigan


File Size: 18.1 kB
Pages: 2
Date: October 23, 2000
File Format: PDF
State: Michigan
Category: Court Forms - Federal
Word Count: 170 Words, 1,098 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.miwd.uscourts.gov/FORMS/csscmpsd.pdf

Download Social Security Complaint Form (Southern Division) ( 18.1 kB)


Preview Social Security Complaint Form (Southern Division)
UNITED STATES DISTRICT COURT WESTERN DISTRICT OF MICHIGAN SOUTHERN DIVISION

, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant. / Case No.

Judge

The above-named plaintiff makes the following representations to this court for the purpose of obtaining judicial review of a decision of the defendant adverse to the plaintiff: 1. The plaintiff (whose Social Security Account number is resident of County State ) is a .

2. The plaintiff complains of a decision which adversely affects the plaintiff in whole or part. The decision has become the final decision of the Secretary for pur poses of judicial review and bears the following caption: In the case of: Claim for:

Claimant Wage Earner

Type of Benefit Social Security Number

3. The plaintiff has exhausted administrative remedies in this matter and this court has jurisdiction for judicial r eview pursuant to 42 U. S.C. ยง 405(g). WHEREF ORE plaintiff seeks judicial review by this court and the entry of a judgment for such relief as may be proper, including costs.

Attorney/Plaintiff's Signature

Address

Telephone Date:

5/95