Revised 05/01 WDNY UNITED STATES DISTRICT COURT WESTERN DISTRICT OF NEW YORK (Your name) Petitioner, vs. SOCIAL SECURITY COMPLAINT -CV- COMMISSIONER OF SOCIAL SECURITY, Respondent Petitioner, , respectfully states:1. This is an action in the nature of a review of the hearing examiners decision pursuant to Section 205(g) of the Social Security Act as amended (42 U.S.C. 405(g)). 2. This matter was /was not (check one) remanded to the Commissioner of Social Security. If the matter was remanded, such remand was by order of the Honorable of the United States District Court for the District of on (date of decision). The docket number of my prior case was 3. I reside at: My telephone number is: My social security number is: 4. Respondent is the Commissioner of Social Security and as such, has full power and responsibility over disability benefits under the Social Security Act as amended. 5. My disability or disabilities are: 6. My disability or disabilities began on (date) >>>> 27. The Bureau of Disability Insurance of the Social Security Administration denied my application because I failed to establish a period of disability and/or because I did not have an impairment or combination of impairments of the severity prescribed by the pertinent provisions of the Social Security Act sufficient to establish a period of disability or to allow disability insurance benefits. 8. After the Social Security Administration initially denied my application for disability benefits, I requested a hearing. On (date) a hearing was held before an Administrative Law Judge. The Administrative Law Judge denied my application for benefits on (date). (You must attach a copy of the decision to the complaint.) 9. I then appealed to the Appeals Council which affirmed the decision of the Administrative Law Judge on (date). (You must attach a copy of the decision to the complaint.)10. The decision of the hearing examiner, as affirmed by the Appeals Council, was erroneous and not supported by either the substantial evidence on the record or the applicable law. 11. I have / have not (check one) filed other actions in U.S. Courts relating to my efforts to obtain Social Security Disability Benefits. If other actions were filed, they are listed below (attach a separate sheet if necessary): Court Name Docket Number Date Filed Date Case Closed (if applicable) WHEREFORE, I respectfully request that: (a) A summons be issued directing respondent to appear before the Court; (b) Respondent be ordered to submit a certified copy of the transcript of the record including evidence upon which the findings and decision complained of are based; (c) Upon such record, this Court should modify the decision of the respondent to grant monthly maximum insurance benefits to me, retroactive to the date of initial disability, or in the alternative remand to the Respondent for reconsideration of the evidence; and (d) Such further relief as may be just and proper under the circumstances of this case.I declare under penalty of perjury that the foregoing is true and correct. Date: Signature Print Name