Complaint (Social Security - Peoria)
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Complaint (Social Security - Peoria) Form. This is a Illinois form and can be use in USDC Central Federal.
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Tags: Complaint (Social Security - Peoria), Illinois Federal, USDC Central
United States District Court
CENTRAL DISTRICT OF ILLINOIS
PEORIA DIVISION
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Plaintiff
vs.
COMMISSIONER OF SOCIAL SECURITY
Defendant
COMPLAINT
The plaintiff is a resident of
.
(City and State)
The plaintiff's Social Security Number has been attached to the copy of the complaint served on the
Commissioner of Social Security.
The plaintiff complains of a decision which adversely affects (him) (her). The decision has become the
final decision of the Commissioner for purposes of judicial review and bears the following caption:
In the case of:
Claim for:
Claimant
Wage Earner
The plaintiff has exhausted administrative remedies in this matter and this Court has jurisdiction for
judicial review pursuant to 42 U.S.C. ยง405(g).
Wherefore, plaintiff seeks judicial review by this Court and the entry of judgment for such relief as may
be proper, including costs.
Signature
Print Name
Address
City
State
Zip
Telephone No.
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