RESET FORM USDC/CIV-012 Personal Data Identification Form for Review of the Decision of the Commissioner of Social Security (Rev. 8/05) UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF WEST VIRGINIA AT SELECT ONE: _______________________________, ( Note: Use initials if a child is claiming benefits) Plaintiff, PERSONAL DATA IDENTIFICATION FORM V. FOR SOCIAL SECURITY APPEALS JoAnne B. Barnhart, Commissioner of Social Security, Defendant. CIVIL ACTION Plaintiff’s name or initials: _______________________________________________________ (first, middle, last and other names used, if any) Plaintiff’s mailing address:________________________________________________________ (street) ________________________________________________________ (city, 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.USCourtForms.com USDC/CIV-012 Personal Data Identification Form for Review of the Decision of the Commissioner of Social Security (Rev. 8/05) 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 email address (if any): ____________________________________________________ ___________________________________ Signature of attorney Signature of plaintiff, if no attorney _____________________________________ Signature of plaintiff, if no attorney American LegalNet, Inc. www.USCourtForms.com