(Del. Rev. 5/2014) Pro Se Social Security Complaint IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF DELAWARE (Plaintiff) V. (Commissioner, Social Security Administration) (Defendant) Civil Action No. (To be assigned by Clerk's Office) COMPLAINT (Pro Se Plaintiff) 1. The plaintiff, whose Social Security Account No. ends in the last four digits ***-**- ____ ____ ____ ____, and whois a resident of (City) , (State, zip code) , seeks judicial review pursuant to 42 U.S.C. 405(g) of an adverse decision of the defendant which has become final and bears the following caption: In the case of Claimant Wage Earner 2. Plaintiff has exhausted administrative remedies. WHEREFORE, plaintiff seeks a judgement for such relief as may be proper including costs and attorney's fees. ***-**-__ __ __ __ (last four digits of Social Security No.) Claim for (Signature) (Print Name) (City) (State) (Zip) Dated: (Area code ) Telephone No. NOTICE Federal Rule of Civil Procedure 5.2 addresses the privacy and security concerns resulting from public access to electronic court files. Under this rule, papers filed with the court should not contain: an individual's full social security number or full birth date; the full name of a person known to be a minor; or a complete financial account number. A filing may include only: the last four digits of a social security number; the year of an individual's birth; a minor's initials; and the last four digits of a financial account number. American LegalNet, Inc. www.FormsWorkFlow.com