UNITED STATES DISTRICT COURT EASTERN DISTRICT OF LOUISIANA CIVIL ACTION Plaintiff versus Social Security Administration COMPLAINT The above-named plaintiff makes the following representation to this court for the purpose of obtaining judicial review of a decision of the defendant adverse to the plaintiff: 1. The plaintiff is a resident of (City), (State) and has a Social Security number ending in the last four digits ***- **- . 2. The plaintiff complains of a decision which adversely affects the plaintiff in whole or in part. The decision has become the final decision of the Commissioner for purposes of judicial review and bears the following caption: In the case of (Claimant) (Wage Earner) Claim for ***- **- (last four digits of Social Security No.) 3. The plaintiff has exhausted administrative remedies in this matter and this court has jurisdiction for judicial review pursuant to 42 U.S.C. 405 (g). WHEREFORE plaintiff seeks judicial review by this court and the entry of a judgment for such relief as may be proper, including costs. Date Signature Printed Name 02/2011 Street Address City, State, Zip Code Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES DISTRICT COURT EASTERN DISTRICT OF LOUISIANA CIVIL ACTION Plaintiff versus Social Security Administration ATTACHMENT PURSUANT TO LR 9.2, THIS ATTACHMENT IS NOT TO BE FILED IN THE RECORD BUT MUST BE SERVED WITH THE COMPLAINT ON THE UNITED STATES ATTORNEY'S OFFICE. A. If this case involves claims for retirement, disability, health insurance and black lung benefits, the full social security number of the worker on whose wage record the application for benefits was filed (whether or not the worker is the plaintiff). (Wage Earner) B. - - (Social Security No.) If this case involves claims for supplemental security income benefits, the full social security number of the plaintiff. (Plaintiff) C. - - (Social Security No.) If this case involves benefits sought for minor child(ren) under Titles II and XVI, the minor child(ren)'s full social security number(s). (Minor Child) (Minor Child) - - (Social Security No.) (Social Security No.) Date Signature Printed Name 02/2011 Street Address City, State, Zip Code Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com