Free Social Security Instruction and Complaint - Alabama

UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF ALABAMA INSTRUCTIONS FOR FILING A COMPLAINT TO PETITION REVIEW OF A DECISION OF SOCIAL SECURITY ADMINISTRATION READ CAREFULLY 1. This packet consists of: 1 complaint form 1 summons forms 1 application to proceed In Forma Pauperis

2. Your complaint must be clearly handwritten or typewritten and signed by each plaintiff. All copies of the complaint must be identical to the original in their wording. It is not necessary to swear to the complaint under oath before a notary public. However, each plaintiff must attest under penalty of perjury that the complaint is true and correct. You are warned that any false statement of a material fact may subject you to prosecution and conviction. 3. All questions must be answered concisely in the proper space on the form. If you need additional space to answer a question, you may use additional blank page(s). YOUR COMPLAINT SHOULD NOT CONTAIN LEGAL ARGUMENTS OR CITATIONS­ YOU ARE ONLY REQUIRED TO GIVE FACTS. 4. Upon receipt of the $350.00 filing fee, your complaint will be filed, IF IT IS IN PROPER ORDER. If you are unable to pay the filing fee, you may petition the court to proceed in forma pauperis. If you wish to proceed in forma pauperis, you must complete, sign, and attest as true and correct under penalty of perjury the enclosed "Application to Proceed In Forma Pauperis" supporting documentation form. 5. The proper parties to be served in a Social Security Complaint, in addition to the named defendant, and their appropriate addresses, are as follows:

Office of Regional Chief Council, Region VIII Social Security Administration Byron G. Rogers Federal Office Building 1961 Stout Street, Suite 1001A Denver, CO 80294

UNITED STATES ATTORNEY GENERAL 5111 Main Justice Building 10th & Constitution Avenue NW Washington, D.C. 20530

UNITED STATES ATTORNEY P.O. Box 197 Montgomery, AL 36101-0197 Michael J. Astrue Social Security Administration Room 611, Altmeyer Building 6401 Security Blvd. Baltimore, MD 21235

6. If you pay the $350.00 filing fee, or if you proceed in forma pauperis, you must also fill out 2 summons forms each for the Commissioner of Social Security, the United States Attorney, the United States Attorney General, and the Office of the Regional Chief Counsel, Region VII. 7. It is YOUR responsibility to notify the Clerk's Office of ANY change of address you may have, in writing, during the entire time your case remains open before the court. Failure to so advise the Clerk of your current address may result in the DISMISSAL of your case. 8. Your complaint will not be considered unless it conforms to these instructions.

IN THE UNITED STATE DISTRICT COURT MIDDLE DISTRICT OF ALABAMA

) ) _______________________________ ) Plaintiff, ) ) v. ) ) ) SOCIAL SECURITY ADMINISTRATION) Defendant, ) COMPLAINT Comes now the plaintiff and alleges as follows: COUNT I 1. 2. This court has jurisdiction to hear this cause pursuant to 42 U.S.C. § 405 (g). The plaintiff_______________________________________, is a resident of name of plaintiff ______________________________________________________________. City and State The defendant is the Commissioner of Social Security. The plaintiff's Social Security number is _______________________. The plaintiff is or has been fully insured under the Social Security Act. The plaintiff filed an application for social security disability insurance benefits. This request or these requests were denied. The final administrative decision was rendered on __________________(date of decision of Appeals Council).

3. 4. 5. 6. 7. 8.

9. 10.

The plaintiff has exhausted all administrative remedies. The Commissioner's decision to deny the plaintiff's application was erroneous and was not supported by substantial evidence in the administrative record. The contention may be set forth more fully in the space that follows:

WHEREFORE, the plaintiff requests that the court reverse the decision of the Commissioner and order the Commissioner to pay to the plaintiff Social Security Disability Insurance Benefits, the costs of this action and, as applicable, supplemental income. The plaintiff further requests all other relief that the court may deem just and proper. Further requests for relief may be set forth more fully on page 3 of this form.

Signature of plaintiff

Typed or printed name

Street Address

City

State

Zip Code

Telephone number (including area code)
FURTHER STATEMENT OF BASIS FOR CLAIM (Optional)

FURTHER REQUEST FOR RELIEF (Optional)

AFFIRMATION OF PLAINTIFF 1. I, _______________________________, the plaintiff in the aforementioned cause, do affirm that I have read all of the statements contained in the complaint and those which are attached in the accompanying financial statement. I believe them to be, to the best of my personal knowledge, true and correct. 2. Moreover, while neither the complaint or the financial affidavit has been notarized, I do understand that this complaint and these affidavits will become an official part of the United States District Court files and that ANY false statements knowingly made by me are illegal and may subject me to criminal penalties.

__________________________ Signature of Plaintiff Date:__________________________

MD AL MODIFIED AO 440 (Rev. 02/09) Summons in a Civil Action

UNITED STATES DISTRICT COURT
for the

__________ District of __________ ) ) ) ) )

Plaintiff

v.
Defendant

Civil Action No.

SUMMONS IN A CIVIL ACTION To: (Defendant's name and address)

A lawsuit has been filed against you. Within 20 days after service of this summons on you -- or 60 days if you are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.P. 12 (a)(2) or (3) -- or 90 days in a Social Security action -- you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff's attorney, whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. You also must file your answer or motion with the court.

DEBRA P. HACKETT, CLERK OF COURT

Date:
Signature of Clerk or Deputy Clerk

MD AL MODIFIED AO 440 (Rev. 02/09) Summons in a Civil Action (Page 2)

Civil Action No. PROOF OF SERVICE (This section should not be filed with the court unless required by Fed. R. Civ. P. 4(1)) This summons for (name of individual and title, if any) was received by me on (date) .

' I personally served the summons on the individual at (place) on (date) ' I left the summons at the individual's residence or usual place of abode with (name) , a person of suitable age and discretion who resides there, on (date) , and mailed a copy to the individual's last known address; or , who is on (date) ' I returned the summons unexecuted because ' Other (specify): . My fees are $ for travel and $ for services, for a total of $ . ; or ; or ; or

' I served the summons on (name of individual) designated by law to accept service of process on behalf of (name of organization)

0.00

I declare under penalty of perjury that this information is true.

Date:
Server's signature

Printed name and title

Server's address

Additional information regarding attempted service, etc:

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IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF ALABAMA ____________________ DIVISION ___________________________________) ___________________________________) ___________________________________) ___________________________________) Plaintiff(s) v. __________________________________) __________________________________) __________________________________) __________________________________) Defendant(s) MOTION TO PROCEED IN FORMA PAUPERIS Plaintiff(s)______________________________________________________________ moves this Honorable Court for an order allowing her/him to proceed in this case without prepayment of fees, costs, or security therefor, and for grounds therefor submits the attached sworn affidavit in support of the motion. __________________________________ Plaintiff(s) signature

AO 240 (Rev. 01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form)

UNITED STATES DISTRICT COURT
for the __________ District of __________ ) ) ) ) )

Plaintiff v. Defendant

Civil Action No.

APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS (Short Form) I am a plaintiff or petitioner in this case and declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief requested. In support of this application, I answer the following questions under penalty of perjury: 1. If incarcerated. I am being held at: . If employed there, or have an account in the institution, I have attached to this document a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months for any institutional account in my name. I am also submitting a similar statement from any other institution where I was incarcerated during the last six months. 2. If not incarcerated. If I am employed, my employer's name and address are:

My take-home pay or wages are: $

per (specify pay period)

.

3. Other Income. In the past 12 months, I have received income from the following sources (check all that apply): (a) Business, profession, or other self-employment (b) Rent payments, interest, or dividends (c) Pension, annuity, or life insurance payments (d) Disability, or worker's compensation payments (e) Gifts, or inheritances (f) Any other sources
' ' ' ' ' '

Yes Yes Yes Yes Yes Yes

' ' ' ' ' '

No No No No No No

If you answered "Yes" to any question above, describe below or on separate pages each source of money and state the amount that you received and what you expect to receive in the future.

AO 240 (Rev. 01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form)

4. Amount of money that I have in cash or in a checking or savings account:

$

.

5. Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or thing of value that I own, including any item of value held in someone else's name (describe the property and its approximate value):

6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and provide
the amount of the monthly expense):

7. Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationship with each person, and how much I contribute to their support:

8. Any debts or financial obligations (describe the amounts owed and to whom they are payable):

Declaration: I declare under penalty of perjury that the above information is true and understand that a false statement may result in a dismissal of my claims.

Date:
Applicant's signature

Printed name

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