UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF NEW YORK FORM COMPLAINT FOR APPEAL OF A DECISION BY THE COMMISSIONER OF SOCIAL SECURITY _________________________________ Plaintiff V. Commissioner of Social Security Defendant __________________________________ Civil Action No : ____-CV-______ The above-named plaintiff makes the following representations to the Court for the purpose of obtaining judicial review of a decision of the defendant adverse to the plaintiff: 1. The plaintiff is a resident of (city) ________________________, in the State of _____________________________. The last four digits of the Plaintiffs social security number are ___ ___ ___ ___. The 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 and bears the following caption: In the case of _________________________ (Claimant) 2. Claim for __________________________ ___ (Last 4 digits of Social Security Number) _________________________ (Wage Earner) ___ ___ ___ 3. 4. A copy of the Action of the Appeals Council is attached to this Complaint. 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). WHEREFORE, plaintiff seeks judicial review by this Court and the entry of judgment for such relief as may be proper, including costs. Dated____________________ ___________________________ Signature of Attorney of Plaintiff Pro Se _______________________________ _______________________________ Address of Attorney or **Plaintiff Pro Se Attorney Bar Roll Number _________ **Pro Se plaintiff(s) shall only provide City and State American LegalNet, Inc. www.FormsWorkFlow.com