Social Security Review
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Social Security Review Form. This is a California form and can be use in USDC Northern Federal.
Loading PDF...
Tags: Social Security Review, California Federal, USDC Northern
1
2
3
4
5
IN THE UNITED STATES DISTRICT COURT
6
FOR THE NORTHERN DISTRICT OF CALIFORNIA
7
8
Case No.
9
Plaintiff,
v.
11
For the Northern District of California
United States District Court
10
12
Defendant.
/
13
14
15
16
17
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
18
19
2.
The plaintiff complains of a decision which adversely affects the plaintiff in whole or in
20
part. The decision has become the final decision of the Secretary for purpose of judicial review and
21
bears the following caption:
22
In the case of
23
24
_______________________________
Claimant
______________________________
Wage Earner
Claim for
___________________________
___________________________
Social Security
25
26
27
28
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
such relief as may be proper, including costs.
2
3
DATE:
______________________________________
Attorney for Plaintiff
4
5
______________________________________
Address
6
______________________________________
Telephone
7
8
9
11
For the Northern District of California
United States District Court
10
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
2
2001 © American LegalNet, Inc.
