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
UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT (Name) Plaintiff, v. Case No. (To be supplied by the Court) COMMISSIONER OF SOCIAL SECURITY, Defendant SOCIAL SECURITY COMPLAINT 1. This is an action seeking court review of the Social Security Administration Office of Disability Adjudication and Review’s 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. Check the type of claim you are filing: _____ Social Security Disability Claim, 42:0405id _____ Supplemental Security Income Claim, 42:1383 _____ Child Disability Claim, 42:0405wc _____ Widow or Widower Claim, 42:0405ww Rev. 7/27/11 American LegalNet, Inc. www.FormsWorkFlow.com 5. List all social security cases you have filed in this court in the last ten (10) years: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 6. 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) 7. . CIRCLE 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, circle letter A, complete this section and proceed to Question 8. Plaintiff was found disabled by the Social Security Administration 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). Rev. 7/27/11 2 American LegalNet, Inc. www.FormsWorkFlow.com B. If you were granted disability benefits but these were LATER TERMINATED OR REDUCED, circle letter B, complete this section and proceed to Question 8. Plaintiff was found disabled by the Social Security Administration 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 (circle one) terminated / reduced, effective ___________________ (date of termination or reduction in amount of payment). C. If your initial application for disability benefits was DENIED, circle C and proceed to Question 8. 8. Following the Social Security Administration action identified in A, B or C above, 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. 9. The decision of the Administrative Law Judge was referred to the Decision Review Board and the decision was (circle one) AFFIRMED / REVERSED IN PART on _____________________ (date). Plaintiff received the decision from the Decision Review Board on _______________________ (date). You must attach a copy of the decision of the Decision Review Board to this complaint, even if the decision only states that the Decision Review Board did not timely review your claim. Rev. 7/27/11 3 American LegalNet, Inc. www.FormsWorkFlow.com If the decision of the Administrative Law Judge was not referred to the Decision Review Board, attach the Social Security Administration Notice stating that fact. Failure to attach a copy of the decision of the Decision Review Board or the Social Security Administration notice may result in your complaint being dismissed for failure to exhaust your administrative remedies. 10. The decision of the Administrative Law Judge, as affirmed by the Decision Review Board if your case was referred, was wrong, not supported by substantial evidence on the record, or contrary to law because ____________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 11. 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 supplemental security income benefits, retroactive to the date of application, 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. Rev. 7/27/11 4 American LegalNet, Inc. www.FormsWorkFlow.com _____________________________ ______________________________ Original signature of attorney (if any) Plaintiff's Original Signature ______________________________ Printed Name Printed Name ) Attorney’s full address and telephone Plaintiff’s full address and telephone Email address if available Email address if available Dated: Rev. 7/27/11 5 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. 7/27/11 6 American LegalNet, Inc. www.FormsWorkFlow.com