IN THE UNITED STATE DISTRICT COURT NORTHERN DISTRICT OF INDIANA Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY Defendant. ) ) ) ) ) ) ) ) ) CASE NO. COMPLAINT Comes now the plaintiff and alleges as follows: 1. The plaintiff, whose social security number is __________________________, is a resident of the county of ___________________, in the State of Indiana. The plaintiff, fully insured under the Social Security Act, has exhausted all administrative remedies by filing an application for social security disability benefits which was denied by the Appeals Council on _______________. 2. The Commissioner’s decision to deny the plaintiff’s application was erroneous and was not supported by substantial evidence in the administrative record because: WHEREFORE, the plaintiff requests that the court reverse the decision of the Commissioner and order the Commissioner to pay benefits, the costs of this action and other relief that the court may deem just and proper. American LegalNet, Inc. www.FormsWorkflow.com VERIFICATION AND SIGNATURE Initial Each Statement and Sign at the Bottom _____ I have included six properly completed summons forms. _____ I have included three properly completed process receipt and return forms (USM-285). _____ In addition to this complaint with an original signature, I have included three additional copies. _____ I have included full payment of the filing fee OR attached a properly completed petition to proceed in forma pauperis. _____ I agree to promptly notify the clerk of any change of address. _____ I have read all of the statements in this complaint. [Do not forget to keep a copy for your records.] _____ I declare under penalty of perjury that the foregoing is true and correct. Signed this ________ day of _________________________, 20____. Signature of Plaintiff _________________________________________ Typed or Printed Name Street Address City State Zip Code _________________________________________ Telephone Number (including area code) 2 American LegalNet, Inc. www.FormsWorkflow.com