(Rev. 12/6/12) UNITED STATES DISTRICT COURT WESTERN DISTRICT OF LOUISIANA DIVISION XXX-XXPlaintiff VS. U.S. Commissioner of Social Security Defendant COMPLAINT The above-named plaintiff makes the following representations to this Court for the purpose of obtaining judicial review of a final decision of defendant adverse to plaintiff. SS# Judge Magistrate Judge Civil Action No. The Court's jurisdiction of this cause is predicated on and invoked pursuant to 42 U.S.C. § 405(g) to review a decision of the Commissioner of the Social Security Administration denying plaintiff's application. This action is an appeal from the final administrative decision denying plaintiff's claim. This action is commenced within the appropriate time period set forth in the Action of Appeals Council on requests for Review. Plaintiff, whose Social Security account number is XXX-XXis a resident of the Parish of , State of Louisiana. , Plaintiff complains of a decision that adversely affects plaintiff in whole or in part. The decision has become the final decision of defendant for purposes of review. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com (Rev. 12/6/12) The decision denying plaintiff's claim is contrary to the law and regulations, and the conclusions and findings of fact of the defendant are not supported by substantial evidence. WHEREFORE, plaintiff prays that this Court: Remand the case for further hearing; Allow the plaintiff to proceed and file this complaint without prepayment of costs. Order such other and further relief the Court deems just and proper. Dated this day of 20 . RESPECTFULLY SUBMITTED: (Signature) (Printed Name) (Street or P.O. Box) (City) (Area) (Telephone) (State) (Zip Code) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com