UNITED STATES DISTRICT COURT DISTRICT OF OREGON DIVISION ____________________________________ ____________________________________ (Enter full name of plaintiff(s)) Civil Case No. _______________ (to be assigned by Clerk of the Court) Plaintiff(s), v. COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant. COMPLAINT FOR JUDICIAL REVIEW OF DECISION BY COMMISSIONER OF SOCIAL SECURITY 1. Plaintiff resides at: Street Address: __________________________ City:___________________________________ County:_________________________________ State:___ ________________________________ Zip Code:_______________________________ Telephone No.:______ _____________________ 2. Plaintiff seeks judicial review of the final decision by the Commissioner of Social Security denying his/her application for Social Security Disability Insurance Benefits and/or Supplemental Security Income disability benefits. 3. Council on 4. Plaintiff received the decision of the Administrative Law Judge on (date) and received notice of the decision or denial of review by the Appeals (date). The final decision of the Commissioner should be (check all that apply): G Reversed and remanded for an award of benefits G Reversed and remanded for further proceedings G Modified SOCIAL SECURITY COMPLAINT Revised: Aug 4, 2010 Page 1 American LegalNet, Inc. www.FormsWorkFlow.com 5. 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). WHEREFORE, Plaintiff seeks judicial review by the Court and entry of judgment of such relief as may be proper. I declare under penalty of perjury that the foregoing is true and correct. Signed this _____ day of ______________________, 20____. _______________________________________ _______________________________________ (Signature of Plaintiff(s)) SOCIAL SECURITY COMPLAINT Revised: Aug 4, 2010 Page 2 American LegalNet, Inc. www.FormsWorkFlow.com