IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF TEXAS ________________ DIVISION _____________________ vs COMMISSIONER, SOCIAL SECURITY ADMINISTRATION CIVIL ACTION NO. ____________ COMPLAINT The above-named Plaintiff makes the following representations to this Court for the purpose of obtaining judicial review of a decision of the Defendant rendered on _________(date) adverse to the Plaintiff: 1. The Plaintiff, whose Social Security Account Number (last four digits only) is ______________, is a resident of ________________(city), and ______________ (state). 2. The Plaintiff complains of a decision which aversely 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 Claim for ________________________________ (Claimant) _____________________________ ________________________________ (Wager Earner) _____________________________ (Social Security Number - last four digits only) 3. The Plaintiff has exhausted administrative remedies in this matter and this Court has jurisdiction for judicial review pursuant to 42 U.S.C. 495(g). 4. The Plaintiff shall effect proper service of process by serving a copy of the summons and complaint upon the local United States Attorney, the Attorney General of the United States, and the Secretary of Health and Human Services within 120 days from the date of filing this complaint according to Rules 4(j) and 4(m) of the Federal Rules of Civil Procedure and Local Court Rule CV-4. Wherefore Plaintiff seeks judicial review by this Court and the entry of a judgment for such relief as may be proper, including costs. _________________________________ Plaintiff or Attorney for Plaintiff _________________________________ Address _________________________________ City, State, Zip _________________________________ Telephone Number American LegalNet, Inc. www.FormsWorkflow.com