Complaint For Appealing Denial Of Social Security Benefits
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Complaint For Appealing Denial Of Social Security Benefits Form. This is a Maryland form and can be use in District Court Federal.
Tags: Complaint For Appealing Denial Of Social Security Benefits, Maryland Federal, District Court
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)
Complaint: Denial of Social Security Benefits (Rev. 7/21/2006)
American LegalNet, Inc.
www.FormsWorkflow.com
CONFIDENTIAL INFORMATION
THIS DOCUMENT MUST BE SERVED ON THE GOVERNMENT
ALONG WITH THE SUMMONS AND COMPLAINT.
IT IS NOT TO BE FILED WITH THE COURT.
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MARYLAND
_____________________________
:
vs.
:
COMMISSIONER, SOCIAL SECURITY
CIVIL ACTION NO. _______________
:
STATEMENT OF SOCIAL SECURITY NUMBER
Social Security Number of Claimant:
Social Security Number of Worker (if different than claimant):
_____________
(Date)
________________________________________________
(Signature)
________________________________________________
________________________________________________
________________________________________________
(Printed name, address, and phone number of Plaintiff)
Complaint: Denial of Social Security Benefits (Rev. 7/21/2006)
American LegalNet, Inc.
www.FormsWorkflow.com
