UNITED STATES DISTRICT COURT WESTERN DISTRICT OF MICHIGAN SOUTHERN DIVISION , Plaintiff, v. Case No. COMMISSIONER OF SOCIAL SECURITY, Judge Defendant. / The above-named plaintiff makes the following representations to this court for the purposeof obtaining judicial review of a decision of the defendant adverse to the plaintiff: 1. The plaintiff (whose Social Security Account number is ) is aresident of . County State 2. The plaintiff complains of a decision which adversely affects the plaintiff in whole orpart. The decision has become the final decision of the Secretary for purposes of judicial reviewand bears the following caption: In the case of: Claim for: Claimant Type of Benefit Wage Earner Social Security Number>>>> 2 3. The plaintiff has exhausted administrative remedies in this matter and this court has jurisdiction for judicial review pursuant to 42 U.S.C. 405(g). WHEREF ORE plaintiff seeks judicial review by this court and the entry of a judgment for such relief as may be proper, including costs. Attorney/Plaintiffs Signature Address Telephone Date: 5/95