MIED ProSe 13 (Rev 5/16) Complaint Review of a Social Security Disability or Supplemental Security Income Decision IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF MICHIGAN Case No. ______________________________ (Write the full name of each plaintiff who is filing this complaint. If the names of all the plaintiffs cannot fit in the space above, please write "see attached" in the space and attach an additional page with the full list of names.) v. COMMISSIONER OF SOCIAL SECURITY (to be filled in by the Clerk's Office) Complaint for Review of a Social Security Disability or Supplemental Security Income Decision NOTICE Except as noted in this form, plaintiff need not send exhibits, affidavits, grievance or witness statements, or any other materials to the Clerk's Office with this complaint. In order for your complaint to be filed, it must be accompanied by the filing fee or an application to proceed in forma pauperis. American LegalNet, Inc. www.FormsWorkFlow.com MIED ProSe 13 (Rev 5/16) Complaint for Review of a Social Security Disability or Supplemental Security Income Decision I. The Parties to This Complaint A. The Plaintiff(s) Provide the information below for each plaintiff named in the complaint. Attach additional pages if needed. Name Street Address City and County State and Zip Code Telephone Number E-mail Address ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________ Your Social Security Number B. The Defendant Provide the information below for the defendant named in the complaint. Attach additional pages if needed. Name COMMISSIONER OF SOCIAL SECURITY II. Basis for Jurisdiction This is an action seeking court review of a decision of the Commissioner of the Social Security Administration. Jurisdiction for such proceedings can be based on two statutes. If this complaint seeks review of a decision regarding Disability Insurance Benefits under Title II of the Social Security Act, jurisdiction is proper under 42 U.S.C. § 405(g). If this complaint seeks review of a decision regarding Supplemental Security Income under Title XVI of the Social Security Act, jurisdiction is proper under 42 U.S.C. § 1383(c)(3). Please check the type of claim you are filing. Claim Type Disability Insurance Benefits Claim (Title II) Supplemental Security Income Claim (Title XVI) Child Disability Claim Widow or Widower Claim For Clerk's Office Use Only COA: 42:0405id NOS: 864 COA: 42:1383 NOS: 863/864 COA: 42:0405wc NOS: 863 COA: 42:0405ww NOS: 863 2 American LegalNet, Inc. www.FormsWorkFlow.com MIED ProSe 13 (Rev 5/16) Complaint for Review of a Social Security Disability or Supplemental Security Income Decision An appeal from a decision of the Commissioner must be filed within 60 days of the date on which you received notice that the Commissioner's decision became final. When did you receive notice that the Commissioner's decision was final? (This is likely the date on which you received notice from the Social Security Appeals Council that your appeal was denied.) Please attach a copy of the Commissioner's final decision, and a copy of the notice you received that your appeal was denied from the Social Security Appeals Council. III. Statement of Claim Federal courts may overturn decisions by the Commissioner of Social Security only if the decision was not supported by substantial evidence in the record or was based on legal error. Why should this court overturn the Commissioner's decision? (Check all that apply) The Commissioner found the following facts to be true, but these facts are not supported by substantial evidence in the record. (Explain why the Commissioner's factual findings are not supported by substantial evidence in the record.) 3 American LegalNet, Inc. www.FormsWorkFlow.com MIED ProSe 13 (Rev 5/16) Complaint for Review of a Social Security Disability or Supplemental Security Income Decision The Commissioner's decision was based on legal error. (Identify all legal errors.) IV. Relief State what you want the court to do (check all that apply): Modify the defendant's decision and grant monthly maximum insurance benefits to the plaintiff, retroactive to the date of initial disability. In the alternative, remand to the defendant for reconsideration of the evidence. Grant any further relief as may be just and proper under the circumstances of this case. V. Certification and Closing Under Federal Rule of Civil Procedure 11, by signing below, I certify to the best of my knowledge, information, and belief that this complaint: (1) is not being presented for an improper purpose, such as to harass, cause unnecessary delay, or needlessly increase the cost of litigation; (2) is supported by existing law or by a nonfrivolous argument for extending, modifying, or reversing existing law; (3) the factual contentions have evidentiary support or, if specifically so identified, will likely have evidentiary support after a reasonable opportunity for further investigation or discovery; and (4) the complaint otherwise complies with the requirements of Rule 11. A. For Parties Without an Attorney I agree to provide the Clerk's Office with any changes to my address where caserelated papers may be served. I understand that my failure to keep a current address on file with the Clerk's Office may result in the dismissal of my case. Date of signing: ____________________, 20____. Signature of Plaintiff Printed Name of Plaintiff ___________________________________________ ___________________________________________ 4 American LegalNet, Inc. www.FormsWorkFlow.com MIED ProSe 13 (Rev 5/16) Complaint for Review of a Social Security Disability or Supplemental Security Income Decision Additional Information: 5 American LegalNet, Inc. www.FormsWorkFlow.com JS 44 Reverse (Rev. 0 /16) INSTRUCTIONS FOR ATTORNEYS COMPLETING CIVIL COVER SHEET FORM JS 44 Authority For Civil Cover Sheet The JS 44 civil cover sheet and the information contained herein neither replaces nor supplements the filings and service of pleading or other papers as required by law, except as provided by local rules of court. This form, approved by the Judicial Conference of the United States in September 1974, is required for the use of the Clerk of Court for th