UNITED STATES DISTRICT COURT WESTERN DISTRICT OF LOUISIANA (Name) (Social Security #) VS. U. S. Commissioner of Social Security 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. The Court’s jurisdiction of this cause is predicated on and invoked pursuant to 42 USC 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 form in the Action of Appeals Council on requests for Review. Plaintiff, whose Social Security account number is resident of the Parish of , State of Louisiana. , is a 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. 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 support 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 s the Court deems just and proper. Dated this day of , 20 RESPECTFULLY SUBMITTED: Phone Number: .