Free Complaint for Review of the Decision of the Commissioner of Social Security (LR Civ P 9.2) - West Virginia


File Size: 44.2 kB
Pages: 2
Date: February 13, 2007
File Format: PDF
State: West Virginia
Category: Court Forms - Federal
Author: ras
Word Count: 266 Words, 3,058 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.wvsd.uscourts.gov/pdfs/ComplaintforReviewofSSAstrue.pdf

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USDC/CIV-013 Complaint for Review of the Decision of the Commissioner of Social Security (Rev. 2/07)

UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF WEST VIRGINIA AT SELECT ONE:

Plaintiff,
V.

COMPLAINT FOR REVIEW OF THE DECISION
OF THE COMMISSIONER OF SOCIAL

SECURITY

MICHAEL J. ASTRUE, Commissioner of Social Security, Defendant.

CIVIL ACTION

Plaintiff's name: ________________________________________________________________
(first, middle, last and other names used, if any)

Plaintiff's current residence: ______________________________________________________
(street, apartment no., etc.)

______________________________________________________
(city, county, state and ZIP code)

Plaintiff's mailing address:

______________________________________________________
(post office box, etc.)

______________________________________________________
(city, county, state and ZIP code)

Child's full name (if Social Security claim is for a child): _________________________________________
(first, middle, last and other names used, if any)

Social Security Number of person claiming benefits: ___________________________________ Social Security Number of parent or other relevant wage earner: __________________________ Date of birth of person claiming benefits: ____________________________________________ Date of death of wage earner (if a survivor's claim): _________________________________________

USDC/CIV-013 Complaint for Review of the Decision of the Commissioner of Social Security (Rev. 2/07)

Jurisdiction and venue is based on 42 U.S.C. 405(g). Date of Appeals Council's decision: ________________________________________________ The decision of the Commissioner should be (select those which apply): Reversed Modified Remanded

because it is not supported by substantial evidence, and/or because the Commissioner committed other error which is _____________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Name of attorney (if any): _________________________________________________________

Attorney's street address: _________________________________________________________ _________________________________________________________ Attorney's telephone number: _____________________________________________________ Attorney's fax number: __________________________________________________________ Attorney's email address: ________________________________________________________

____________________________________ Signature of attorney If the plaintiff is not represented by an attorney, complete the following: Plaintiff's telephone number (if any):__________________________________________________ Plaintiff's fax number (if any): ______________________________________________________ Plaintiff's e-mail address (if any): ____________________________________________________

____________________________________ Signature of plaintiff, if no attorney