Complaint (Social Security - Springfield)
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Complaint (Social Security - Springfield) Form. This is a Illinois form and can be use in USDC Central Federal.
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Tags: Complaint (Social Security - Springfield), Illinois Federal, USDC Central
UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF ILLINOIS
SPRINGFIELD DIVISION
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Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY,
Defendant.
Case No.:
_____________
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:
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
2000 (C) American LegalNet, Inc.
Telephone No.________________________
2
2000 (C) American LegalNet, Inc.
