Complaint - Social Security Commissioner
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Complaint - Social Security Commissioner Form. This is a Maryland form and can be use in District Court Federal.
Tags: Complaint - Social Security Commissioner, Maryland Federal, District Court
APPENDIX A
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MARYLAND
_____________________________
:
_____________________________
:
_____________________________
:
vs.
:
COMMISSIONER, SOCIAL SECURITY
CIVIL ACTION NO. _______________
:
COMPLAINT
l.
Plaintiff is a resident of ________________________________________________.
(Provide your City or County and State of residence)
2.
Plaintiff complains of a decision against him/her bearing the following caption:
IN THE CASE OF:
CLAIM FOR:
_____________________________
(Claimant)
____________________________
(Type of benefits)
_____________________________
(Wage Earner if Different from Claimant)
3.
The date of the final decision by the Secretary against plaintiff is ______________.
4.
Plaintiff claims that the final decision of the Secretary is erroneous as a matter of
fact and as a matter of law.
WHEREFORE plaintiff seeks judicial review by this Court pursuant to 42 U.S.C. Section
405(g), and entry of judgment for such relief as may be proper, including costs.
_____________
(Date)
________________________________________________
(Signature)
________________________________________________
________________________________________________
________________________________________________
(Printed name, address, and phone number of Plaintiff)
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