SOCIAL SECURITY / SUPPLEMENTAL SECURITY INCOME IMPORTANT INFORMATION CONCERNING YOUR COMPLAINT FOR SOCIAL SECURITY OR SUPPLEMENTAL SECURITY INCOME PLEASE KEEP THIS INFORMATION SHEET Filing the Complaint (1) The cost of filing an action is $400. If you cannot afford to pay the fee, you may ask the Court to waive the fee by completing an application to proceed in forma pauperis. You must submit three (3) copies of the complaint, along with a copy of the Appeals Council letter and any other attachments for each copy of the complaint. The complaint is a fill-in-the-blanks form that is not difficult to complete. If necessary, you should ask a friend or relative for help in preparing your papers. It is most important that you (a) submit the complaint to the Court's Pro Se Office within 60 days from the date you received the Appeals Council letter and (b) attach a copy of the Appeals Council letter to the complaint. If you have not received an Appeals Council letter from the Social Security Administration, it may mean that you have not exhausted all your administrative remedies within the agency. If you received the Appeals Council letter much later than the date stamped on the letter, you should also include a copy of the postmark from the envelope. All papers must be in English. The Pro Se Office will assist you with any questions you may have regarding the Court's procedures and forms, but the Pro Se Office staff cannot write or complete any of the forms which are necessary to file the complaint or to proceed with the case. The Pro Se Office is open from Monday through Friday, 8:30 a.m. to 5:00 p.m. (except federal and court holidays). Pro Se Office United States District Court Eastern District of New York 225 Cadman Plaza East Brooklyn, NY 11201 (718) 613-2665 Continued (2) (3) (4) (5) American LegalNet, Inc. www.FormsWorkFlow.com What it means to be Pro Se By filing this action pro se, it means that you are representing yourself and that you do not have an attorney. The Court will not automatically appoint an attorney to represent you in this matter since this is a civil case. You have the right to represent yourself in court and the case will proceed without an attorney. Request for Pro Bono Counsel You may apply for an attorney from the Court's volunteer Pro Bono Panel by filing an "Application for the Court to Request Counsel" and by serving a copy of the application on the defendant's attorney. This form and information concerning the Pro Bono Panel is available from the Pro Se Office. Unfortunately, there is no guarantee that an attorney will volunteer to take your case even if the Court grants your request. Private Attorneys You may hire a private lawyer, however, you must arrange the terms and conditions of such legal representation. Please make sure you understand the terms, conditions and fees before you sign an agreement to hire your own lawyer. The Court cannot recommend any particular attorney, but you may call the Association of the Bar of the City of New York's Legal Referral Service at (212) 626-7373 (English) or (212) 626-7374 (Spanish) for referrals to lawyers who handle Social Security and/or SSI cases. ***** rev. 4/23/13 American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK --------------------------------------- X : (Your Name) Plaintiff, -againstCommissioner of Social Security, : : : : COMPLAINT Defendant. : --------------------------------------- X Plaintiff respectfully alleges: 1. This is an action seeking court review of the decision of the Administrative Law Judge pursuant to section 205(g) and/or section 1631(c)(3) of the Social Security Act, as amended, 42 U.S.C. § 405(g) and/or § 1383(c)(3). 2. Plaintiff resides at . 3. 4. Defendant is the Commissioner of Social Security. Plaintiff became entitled to receive disability insurance benefits and/or Supplemental Security Income benefits because of the following disability __________________________________________________________________________. 5. 6. The disability began on this date That the Bureau of Disability Insurance of the Social Security . Administration disallowed plaintiff's application upon the ground that 1 American LegalNet, Inc. www.FormsWorkFlow.com plaintiff failed to establish a period of disability and/or upon the ground that plaintiff did not have an impairment or combination of impairments of the severity prescribed by the pertinent provisions of the Social Security Act to establish a period of disability or to allow disability insurance benefits or Supplemental Security Income benefits. 7. Subsequent thereto, plaintiff requested a hearing, and on [date of hearing], a hearing was held which resulted in a denial of plaintiff's claim on Law Judge decision]. 8. Thereafter, plaintiff requested review by the Appeals Council, [date of Administrative and after its consideration, the decision of the Administrative Law Judge was affirmed on Plaintiff received this letter on [date of Appeals Council letter]. , thereby making the Administrative Law Judge's decision the "final decision" of the Commissioner, subject to Judicial Review pursuant to 42 U.S.C. § 405(g) and/or § 1383(c)(3). IMPORTANT: ATTACH A COPY OF THE APPEALS COUNCIL LETTER TO THE BACK OF THIS COMPLAINT. 9. The decision of the administrative law judge was erroneous, not supported by substantial evidence on the record and/or contrary to the law. Wherefore, plaintiff respectfully prays that: (a) Court; (b) Defendant be ordered to submit a certified copy of the A summons be issued directing defendant to appear before the transcript of the record, including the evidence upon which the findings 2 American LegalNet, Inc. www.FormsWorkFlow.com and decision complained of are based; (c) Upon such record, this Court should modify the decision of the defendant to grant monthly maximum insurance and/or Supplemental Security Income benefits to the plaintiff, retroactive to the date of the initial disability, or in the alternative, remand to the Commissioner of Social Security for reconsideration of the evidence; and, (d) For such other and further relief as may be just and proper. Dated: Plaintiff's Signature __________________________________ Social Security Number Print Name Address City, State Zip Code Area Code and Telephone Number EDNY Form Revised 4/10/2006 3 American LegalNet, Inc. www.FormsWorkFlow.com