Social Security Complaint Form. This is a Connecticut form and can be use in District Court Federal.
Tags: Social Security Complaint, Connecticut Federal, District Court
Effective 11-15-2018 IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF CONNECTICUT , ) ) Plaintiff, ) ) v. ) Civil Action No. ) , ) Commissioner of Social Security, ) ) Defendant. ) Complaint for Review of Social Security Administration Decision 1. Plaintiff222s name is: . Plaintiff also uses or has used the following other name(s) (if applicable): . Plaintiff lives in (name of State), in (name of city or town). 2. The Plaintiff222s full Social Security number is --. 3. If Plaintiff is filing this case on behalf of someone else over the age of 18, that other person222s full name is , and his/her full Social Security number is --. 4. If Plaintiff is filing on behalf of a minor under age 18, the minor222s initials are , and his/her full Social Security number is --. 5. Defendant is the Commissioner of Social Security. 6. Plaintiff is bringing this action under section 205(g) of the Social Security Act, 42 U.S.C. 247 405(g), to review a final decision of the Commissioner of Social Security as to a claim American LegalNet, Inc. www.FormsWorkFlow.com Effective 11-15-2018 (or claims) under: (check the box that applies) Title II (for claims relating to a period of disability and disability insurance benefits), Title XVI (for claims relating to supplemental security income), both Title II and Title XVI, or other title(s) of the Social Security Act. Plaintiff has exhausted all administrative remedies. An Administrative Law Judge issued a decision on . (If applicable) The Appeals Council denied Plaintiff222s request for review or granted Plaintiff222s request for review and issued a decision on . 7. Plaintiff disagrees with the decision in this case because it is not supported by substantial evidence and/or contains errors of law. 8. Plaintiff asks that the Commissioner222s final decision be reviewed and set aside and that the case be remanded for a new hearing and decision, modified, or reversed for a calculation of benefits, and for any other relief as the Court deems appropriate. Date: If Plaintiff is unrepresented: Signature: Printed name: Plaintiff222s address: American LegalNet, Inc. www.FormsWorkFlow.com Effective 11-15-2018 Plaintiff222s telephone: Plaintiff222s email address: If Plaintiff is represented: Signature: Name of attorney: Attorney222s federal bar no.: Attorney222s address: Attorney222s telephone: Attorney222s fax: Attorney222s email address: American LegalNet, Inc. www.FormsWorkFlow.com