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United States District Court
CENTRAL DISTRICT OF ILLINOIS
PEORIA DIVISION

Plaintiff vs. COMMISSIONER OF SOCIAL SECURITY Defendant

) ) ) ) ) Case No. ) ) ) )

COMPLAINT . (City and State) The plaintiff's Social Security Number has been attached to the copy of the complaint served on the Commissioner of Social Security. The plaintiff complains of a decision which adversely affects (him) (her). 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 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 judgment for such relief as may be proper, including costs. Signature Print Name Address City Telephone No. State Zip Claim for: The plaintiff is a resident of