IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND * * (Full name and address of plaintiff) Plaintiff, * v. Commissioner, Social Security. * Case No. COMPLAINT FOR DENIED SOCIAL SECURITY CLAIM 1. Plaintiff is a resident of (City or County and State) 2. . Plaintiff complains of a decision against him/her bearing the following caption: CLAIM FOR: Type of benefits IN THE CASE OF: Claimant Wage Earner if Different from Claimant 3. 4. The date of the final decision by the Commissioner against plaintiff is Plaintiff claims that the final decision of the Commissioner 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 Telephone number ComplaintDenialSocSecBen (07/2015) 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 * Plaintiff, * v. * Defendant. * STATEMENT OF SOCIAL SECURITY NUMBER Social Security Number of Claimant: Social Security Number of Worker (if different than claimant): Case No. Date Signature Printed name Address Email address Telephone number Fax number ComplaintDenialSocSecBen (07/2015) American LegalNet, Inc. www.FormsWorkFlow.com