USDC/CIV-013 Complaint for Review of the Decision of the Commissioner of Social Security (Rev. 2/07) UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF WEST VIRGINIA AT SELECT ONE: Plaintiff, COMPLAINT FOR REVIEW OF THE DECISION OF THE COMMISSIONER OF SOCIAL V. MICHAEL J. ASTRUE, Commissioner of Social Security, SECURITY CIVIL ACTION Defendant. Plaintiff’s name: ________________________________________________________________ (first, middle, last and other names used, if any) Plaintiff’s current residence: ______________________________________________________ (street, apartment no., etc.) ______________________________________________________ (city, county, state and ZIP code) Plaintiff’s mailing address: ______________________________________________________ (post office box, etc.) ______________________________________________________ (city, county, state and ZIP code) Child’s full name (if Social Security claim is for a child): _________________________________________ (first, middle, last and other names used, if any) Social Security Number of person claiming benefits: ___________________________________ Social Security Number of parent or other relevant wage earner: __________________________ Date of birth of person claiming benefits: ____________________________________________ Date of death of wage earner (if a survivor’s claim): _________________________________________ American LegalNet, Inc. www.FormsWorkflow.com USDC/CIV-013 Complaint for Review of the Decision of the Commissioner of Social Security (Rev. 2/07) Jurisdiction and venue is based on 42 U.S.C. § 405(g). Date of Appeals Council’s decision: ________________________________________________ The decision of the Commissioner should be (select those which apply): Reversed Modified Remanded because it is not supported by substantial evidence, and/or because the Commissioner committed other error which is _____________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Name of attorney (if any): _________________________________________________________ Attorney’s street address: _________________________________________________________ _________________________________________________________ Attorney’s telephone number: _____________________________________________________ Attorney’s fax number: __________________________________________________________ Attorney’s email address: ________________________________________________________ ____________________________________ Signature of attorney If the plaintiff is not represented by an attorney, complete the following: Plaintiff’s telephone number (if any):__________________________________________________ Plaintiff’s fax number (if any): ______________________________________________________ Plaintiff’s e-mail address (if any): ____________________________________________________ ____________________________________ Signature of plaintiff, if no attorney American LegalNet, Inc. www.FormsWorkflow.com