Complaint For Judicial Review Of Decision Of The Commissioner Of Social Security
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Complaint For Judicial Review Of Decision Of The Commissioner Of Social Security Form. This is a Missouri form and can be use in District Court Federal.
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Tags: Complaint For Judicial Review Of Decision Of The Commissioner Of Social Security, Missouri Federal, District Court
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
DIVISION
,
Plaintiff,
v.
Michael J. Astrue, Commissioner
of the Social Security Administration,
Defendant.
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Case No.
(To be assigned by Clerk of District Court)
COMPLAINT FOR JUDICIAL REVIEW OF DECISION
OF THE COMMISSIONER OF SOCIAL SECURITY
I.
Plaintiff,
, resides at
,
,
street address
city
,
state
,
zip code
county
.
telephone number
.
II.
The last four digits of Plaintiff’s social security number are
III.
Plaintiff complains of a decision which adversely affects the plaintiff in whole or in part.
The decision has become the final decision of the Commissioner for purposes of judicial
review.
IV.
The final decision of the Commissioner was not based on substantial evidence in the
record because:
.
(State plainly why Plaintiff is entitled to relief. Attach additional pages if necessary.)
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V.
The date on which Plaintiff received notice of the decision of the Appeals Council:
; or, if no review by the Appeals Council was sought,
the date on which Plaintiff received the decision of the Administrative Law Judge:
.
VI.
The final decision of the Commissioner should be
(Indicate whether the decision should be remanded, modified, and/or reversed.)
VII.
Plaintiff has exhausted all administrative remedies in this matter and this Court has
jurisdiction for judicial review pursuant to 42 U.S.C. § 405(g).
VIII.
Venue is proper in this District because the plaintiff resides within this District and/or has
his or her principal place of business within this District.
.
WHEREFORE, Plaintiff seeks judicial review by this Court and entry of judgment of such
relief as may be proper, including costs.
Signature of attorney or pro se Plaintiff
Date
Address
Telephone
-2-
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