UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF ILLINOIS SPRINGFIELD DIVISION ) ) ) ) ) ) ) ) )
Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.
COMPLAINT The plaintiff is a resident of ___________________________. (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: Claim for: _________________________ 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 State Zip _____________________________