UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT Plaintiff (Name) v. Case No. (To be supplied by the Court) COMMISSIONER OF SOCIAL SECURITY, Defendant SOCIAL SECURITY APPEAL COMPLAINT 1. This is an action seeking court review of the Bureau of Hearings and Appeals' decision pursuant to Section 205(g) of the Social Security Act, as amended, 42 U.S.C. § 405(g). 2. Plaintiff resides at the following location: 3. Defendant is the Commissioner of Social Security, and as such has full power and responsibility over disability benefits under the Social Security Act. 4. List all cases you have filed in this court in the last ten (10) years. Use additional sheets if necessary: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 5. Plaintiff should have been entitled to receive (or should continue to receive) disability benefits (disability income benefits and/or supplemental security income benefits) because of the following disability This disability began on (give date) 6. . CHECK NEXT TO LETTER A, B or C, WHICHEVER IS APPLICABLE TO YOUR CASE, AND FILL IN THE APPROPRIATE BLANKS: A. If you were granted disability benefits but you disagree with the AMOUNT, check letter A and complete this section. Plaintiff was found disabled by the Social Security office on ________________. This disability was found to have begun on ___________________ (date of disabling condition) and plaintiff was granted disability benefits which started on __________________ (date of first payment). B. If you were granted disability benefits but these were LATER TERMINATED OR REDUCED, check letter B and complete this section. Plaintiff was found disabled by the Social Security office on ________________. This disability was found to have begun on ____________________ (date of disabling condition) and plaintiff was granted disability benefits which started on ________________ (date of first payment). Subsequently, plaintiff's benefits were (check one) terminated 2 American LegalNet, Inc. www.FormsWorkflow.com reduced, effective ___________________ (date of termination or reduction in amount of payment). C. If your initial application for disability benefits was DENIED, check C. The Social Security Administration denied plaintiff's application upon the ground that the plaintiff failed to establish a period of disability; and/or upon the ground that the plaintiff did not have an impairment, or combination of impairments, of the severity prescribed by the pertinent provisions of the Social Security Act needed to establish a period of disability; or did not allow full benefits retroactive to the date of initial disability. 7. Subsequently, plaintiff requested a hearing, and on _______________________ (date), a hearing was held before an Administrative Law Judge which resulted in a denial of plaintiff's claim on ________________ (date) or in a finding of disability at a date later than plaintiff's claimed date of disability. 8. Plaintiff requested a review of the Administrative Law Judge's decision by the Appeals Council, and after consideration by the Appeals Council, the decision was (check one) AFFIRMED REVERSED IN PART on _____________________ (date). Plaintiff received this decision on _______________________ (date). You must attach a copy of the decision of the Appeals Council to this complaint. 9. The decision of the Administrative Law Judge, as affirmed by the Appeals Council, was wrong, not supported by substantial evidence on the record, or contrary to law because ___________________________________________________________ _____________________________________________________________________ 3 American LegalNet, Inc. www.FormsWorkflow.com _____________________________________________________________________ _____________________________________________________________________ 10. WHEREFORE, Plaintiff prays that: a. Defendant be ordered to submit a certified copy of the transcript of the record, including evidence upon which the findings and decision complained of are based; b. Upon this record, the district court should modify the decision of the defendant to grant maximum monthly disability benefits to the plaintiff, retroactive to the date of initial disability; or, in the alternative, remand to the Commissioner for further administrative proceedings; and c. For such further relief as may be just and proper under the circumstances of this case. _____________________________ Original signature of attorney (if any) ______________________________ Plaintiff's Original Signature ______________________________ Printed Name and full address Printed Name and full address ______________________________ ________________________________ ( ) Attorney’s telephone ( ) Plaintiff’s telephone Email address if available Email address if available Dated: 4 American LegalNet, Inc. www.FormsWorkflow.com DECLARATION UNDER PENALTY OF PERJURY The undersigned declares under penalty of perjury that he/she is the plaintiff in the above action, that he/she has read the above complaint and that the information contained in the complaint is true and correct. 28 U.S.C. § 1746; 18 U.S.C. § 1621. Executed at _________________________ on ________________________. (location) (date) ________________________________ Plaintiff's Original Signature (Rev. 9/24/08) 5 American LegalNet, Inc. www.FormsWorkflow.com