UNITED STATES DISTRICT COURT DISTRICT OF MINNESOTA _______________________________ Plaintiff, vs. Commissioner of Social Security, Defendant. Case No. __________________________ (To be assigned by Clerk of District Court) COMPLAINT FOR JUDICIAL REVIEW OF DECISION OF THE COMMISSIONER OF SOCIAL SECURITY PARTIES 1. The Plaintiff resides within the District of Minnesota. 2. Defendant Commissioner of Social Security. JURISDICTION 3. This is an action to review a final decision of the Defendant Commissioner of Social Security. This Court has jurisdiction over the action under Section 205(g) of the Social Security Act, as amended, 42 U.S.C. § 405(g). FACTUAL ALLEGATIONS 4. The Plaintiff filed application(s) for disability benefits and/or supplemental security income with the Defendant, and after various administrative proceedings has been denied benefits. American LegalNet, Inc. www.FormsWorkFlow.com The final decision of the Commissioner was not based on substantial evidence in the record and contains the following errors of law: (state each alleged error that entitles the Plaintiff to relief in numbered paragraphs, beginning with 5). 5. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________. Attach additional sheets of paper as necessary. Check here if additional sheets of paper are attached: Please continue to number the paragraphs consecutively. REQUEST FOR RELIEF The Plaintiff requests that the final decision of the Defendant be reversed for an award of benefits or, alternatively, either modified or remanded for further proceedings. SOCIAL SECURITY NUMBER Pursuant to Local Rule 9.1, the wage earner's social security number has been attached to the copy of the complaint served on the Commissioner of Social Security. Date:_____________ ______________________________________ Signature of Plaintiff Mailing Address _________________________________________ _________________________________________ _________________________________________ Telephone Number _________________________________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com