Free Social Security Complaint - Missouri

UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MISSOURI DIVISION ) ) ) ) ) ) ) ) ) ) )

, Plaintiff, v.

Case No. (To be assigned by Clerk of District Court)

Michael J. Astrue, Commissioner of the Social Security Administration, Defendant.

COMPLAINT FOR JUDICIAL REVIEW OF DECISION OF THE COMMISSIONER OF SOCIAL SECURITY

I.

Plaintiff, , street address , state zip code , telephone number city ,

, resides at

county .

II. III.

The last four digits of Plaintiff's social security number are

.

Plaintiff complains of a decision which adversely affects the plaintiff in whole or in part. The decision has become the final decision of the Commissioner for purposes of judicial review. The final decision of the Commissioner was not based on substantial evidence in the record because:

IV.

. (State plainly why Plaintiff is entitled to relief. Attach additional pages if necessary.)

V.

The date on which Plaintiff received notice of the decision of the Appeals Council: ; or, if no review by the Appeals Council was sought, the date on which Plaintiff received the decision of the Administrative Law Judge: . The final decision of the Commissioner should be (Indicate whether the decision should be remanded, modified, and/or reversed.) Plaintiff has exhausted all administrative remedies in this matter and this Court has jurisdiction for judicial review pursuant to 42 U.S.C. § 405(g). Venue is proper in this District because the plaintiff resides within this District and/or has his or her principal place of business within this District. WHEREFORE, Plaintiff seeks judicial review by this Court and entry of judgment of such relief as may be proper, including costs. .

VI.

VII.

VIII.

Signature of attorney or pro se Plaintiff

Date

Address

Telephone

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