COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. Revised 03/02 WDNY : UNITED STATES DISTRICT COURT Calendar No. WESTERN DISTRICT OF NEW YORK : Plaintiff(s) JUDICIAL SUBPOENA HOW TO FILE YOUR SOCIAL SECURITY SHARPE MOTION -against: : IMPORTANT NOTICE: Do NOT File this Motion Unless at Least 120 Days Has Elapsed Since You Requested a Hearing : (Or Since Your Hearing Was Held But No Decision Has Yet Issued) Defendant(s) : ......... ........ ....... .. .. .. ..... ...... . ... IMPORTANT: . You must .accurately. fill.out.the .correct. number .of .forms and submit them to the Court. If you fill out the forms incorrectly and/or send the wrong number of forms, they will be returned to you. Check the Western District’s web site at www.nywd.uscourts.gov for copies of THE PEOPLE OF THEmany of OF NEW YORK and other useful information. STATE the Court’s forms I. MOTION TO 1. Fill out the motion form completely, supplying all requested information in the spaces provided. You will need to submit a total of four copies of the form: one for the Court, one for the respondent, one for the United GREETINGS: States Attorney, and one for the United States Attorney General. Be sure to sign the motion. Keep one copy for your own personal file. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before the Honorable a copy of the letter from the Social the at Security Administration advising you of your right to file this , Court 2. Attach located at County of motion to each copy of the motion form. in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 3. II. Be sure to provide all docket numbers and courts of any prior federal cases regarding this claim, if any. FILING FEE Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a In order to failure completed result of your file the to comply. motion and other necessary papers, you must pay a $30.00 filing fee by personal check, money order, certified check, or official check made out to "Clerk, United States District Court". If you file in person, youHonorable cash. You may also file a motion to proceed in forma pauperis (as the Witness, may pay in , one of the Justices of a poor person); if you Court inqualify, you will not be required to pay the filing fee. County, day of , 20 III. CIVIL COVER SHEET (Attorney must sign above and type name below) Fill out the "Civil Cover Sheet" according to these instructions: 1(a). Print your name as Plaintiff; 1(b). Print "Commissioner of Social Security" as Defendant; 1(c). Print "Pro Se" under Plaintiff's Attorney; 1(d). Put "United States Attorney, Buffalo, New York" as Defendant's Attorney; 2. Telephone No.: Facsimile No.: Basis for Jurisdiction: check Box No. 2: U.S. Defendant; E-Mail Address: Mobile Tel. No.: Attorney(s) for Office and P.O. Address American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. : JUDICIAL SUBPOENA 3. Citizenship of Principal Parties: leave blank; Plaintiff(s) 4. Cause of Action: Write "42 U.S.C. § 405(g)" and "Sharpe Motion" 5. Nature of Suit: Write "Miscellaneous Civil" in the space after the words "(Put an X in one box only).” DO : NOT CHECK ANY BOXES AT ALL. -against- : : Defendant(s) : . .6.. . . . . Origin: .check .Box .No.. 1:. Original . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Proceeding; 7. Requested in Complaint: leave blank; THE PEOPLE OF THE STATE OF NEW YORK 8. TO 9. Related Case(s) if any: if you have ever filed another federal lawsuit relating to social security benefits, write the name of the court and the docket number; and Date and sign your name followed by "Pro Se" on the last line. GREETINGS: IV. MAILINGCOMMAND YOU, that all business and excuses being laid aside, you and each of you attend before WE INSTRUCTIONS , the Honorable at the Court located at County ofbring or mail all of the above papers to either one of the addresses below: Finally, in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the United States District Court Clerk United States District Court Clerk 304 U.S. Courthouse 2120 U.S. Courthouse 68 Court Street 100 State Street Your failure to York 14202-3498 comply with this subpoena is punishable as a contempt of court and will make you liable to Buffalo, New Rochester, New York 14614-1387 the party on whose behalf this(716) 551-5759 (716) 551-4211 or subpoena was issued for a maximum penalty of $50 and all damages sustained as a (585) 263-6263 result of your failure to comply. V. Witness, Honorable Court in County, GENERAL INFORMATION , one of the Justices of the day of , 20 1. Except for your motion, you must send a copy of every legal paper that you send to the Court to the respondent's attorney as well. The Court will serve only your motion, not any subsequent papers. You may (Attorney must sign above and type name below) obtain a form for your affidavit/affirmation of such service from the Clerk’s Office or the Western District web site. 2. You do not need to attach "exhibits" to your original motion and its copies other than a copy of the letter you received advising you of your right to file this motion because your hearing and/or determination has been unreasonably delayed. You must submit enough copies for all the copies of the motion. 3. You must notify the Clerk's Office and all respondents (or their attorneys) of any address changes. Failure to do so may result in dismissal of your motion pursuant to Local Rule of Civil Procedure 5.3(d). The Local Rules are available on the Western District web site. Telephone No.: Attorney(s) for Office and P.O. Address 5. Facsimile No.: E-Mail Address: The Clerk of Court will not file your motion unless it conforms to these instructions and to these forms Mobile Tel. No.: pursuant to Local Rules of Civil Procedure 5.2 and 5.3. 2 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Revised 03/02 WDNY Plaintiff(s) -againstUNITED STATES DISTRICT COURT WESTERN DISTRICT OF NEW YORK Calendar No. : JUDICIAL SUBPOENA : : : Defendant(s) : (Print .your. name) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ..... Petitioner, _____-CV-___________ THE PEOPLE OF THE STATE OF NEW YORK vs. SHARPE MOTION FOR A PROMPT HEARING AND DETERMINATION TO COMMISSIONER OF SOCIAL SECURITY, GREETINGS: 1. 2. 3. Respondent WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of I, , respectfully state: in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the This is a motion for an Order directing the Social Security Administration to provide me with a prompt hearing and/or decision and to pay me interim benefits pending the resolution in my case. See Sharpe v. Sullivan, 1990 WL 4016 (S.D.N.Y. 1990), and Sharpe v. Heckler, 1985 WL 2898 (S.D.N.Y. 1985). Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a I requested a hearing before an Administrative Law Judge on result of your failure to comply. (Applicant shouldHonorable of the following statements.) Witness, check one , one of the Justices of the ____ No hearing has as yet been scheduled. I believe20 this delay is unreasonable. that Court in County, day of , ____ No decision has as yet been scheduled. I believe that this delay is unreasonable. 4. I have been informed by the Social Security Administration of my right tosign above thistype name below) dated (Attorney must request and Order by letter 5. I reside at: Attorney(s) for 6. My telephone number is: Office and P.O. Address 7. My social security number is: 1 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : 8. Calendar No. : Respondent is the Commissioner of Social Security, and as such, has full power and responsibility over disability JUDICIAL SUBPOENA Plaintiff(s) benefits under the Social Security Act as amended. -against- 9. Index No. : My disability or disabilities are: : : 10. Defendant(s) : . .My. disability.or. disabilities.began. on . . . . . . . . . . . . . . . . . . . . . . . .. ....... . ........ .... .. 11. I have THE PEOPLE /have not STATE filedNEW YORK in U.S. Courts relating to my efforts to obtain Social Security OF THE OF other actions Disability Benefits. If other actions were filed, they are listed below (attach a separate sheet if necessary): TO Court Name Docket Number Date Filed Date Case Closed (if applicable) GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed WHEREFORE, I respectfully request that: or adjourned date, to testify and give evidence as a witness in this action on the part of the (a) (b) (c) Respondent be ordered to provide me with a prompt hearing of and/or decision on my claim; Your failure to comply of the following: Yes ____ or No contempt of court and will make to liable to Applicant should check one with this subpoena is punishable as a _____: Respondent be orderedyou pay me the party benefits pending this hearing and/or decision. a maximum penalty of $50 and all damages sustained as a interim on whose behalf this subpoena was issued for result of your failure to comply. Such further relief as may be just and proper under the circumstances of this case. Witness, Honorable Court in County, , one of the Justices of the day of , 20 I declare under penalty of perjury that the foregoing is true and correct. (Attorney must sign above and type name below) Date: Signature (Print Name Attorney(s) for Below) Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 2 American LegalNet, Inc. www.USCourtForms.com