1 2 3 4 5 6 7 8 9 10 v. Plaintiff, Case No. IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF CALIFORNIA United States District Court 11 For the Northern District of California 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 2. Defendant. / The above-name plaintiff makes the following representations to this court for the purpose of obtaining judicial review of a decision of the defendant adverse to the plaintiff: 1. The plaintiff (whose Social Security Account No. is ________________, is a resident of ________________________, _________________. City State The plaintiff complains of a decision which adversely affects the plaintiff in whole or in part. The decision has become the final decision of the Secretary for purpose of judicial review and bears the following caption: In the case of _______________________________ Claimant ______________________________ Wage Earner Claim for ___________________________ ___________________________ Social Security 3.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 the plaintiff seeks judicial review by this court and the entry of judgment for 2001 © American LegalNet, Inc. 1 2 3 4 5 6 7 8 9 10 such relief as may be proper, including costs. DATE: ______________________________________ Attorney for Plaintiff ______________________________________ Address ______________________________________ Telephone United States District Court 11 For the Northern District of California 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 2 2001 © American LegalNet, Inc.