Pro Se: SSA Complaint-Wyo United States District Court District of Wyoming (In the space above enter the full name of the plaintiff) -againstCOMMISSIONER OF SOCIAL SECURITY Case No. ___________________ (To be filled out by Clerk's Office only) COMPLAINT FOR JUDICIAL REVIEW OF SOCIAL SECURITY DECISION NOTICE Federal Rule of Civil Procedure 5.2 addresses the privacy and security concerns resulting from public access to electronic court files. Under this rule, papers filed with the court should not contain: an individual's full social security number or full birth date; the full name of a person known to be a minor; or a complete financial account number. A filing may include only: the last four digits of a social security number; the year of an individual's birth; a minor's initials; and the last four digits of a financial account number. I. Plaintiff is a resident of the County of _________________ and the State of _________________________. The last four digits of the Plaintiff's social security number are __ __ __ __. Plaintiff complains the Commissioner's final decision dated ___ /___ / ___ adversely affects the plaintiff in whole or in part. Attached is the Commissioner's final decision notifying plaintiff of right to sue, which bears the following caption: II. Name of Claimant Claim for (Disability, Survivor's Benefits, Etc.) Last four digits of Wage Earners Social Security Number Name of Wage Earner Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Pro Se: SSA Complaint-Wyo III. Please check the type of claim you are filing. Claim Type Disability Insurance Benefits Claim (Title II) Supplemental Security Income Claim (Title XVI) Child Disability Claim Widow or Widower Claim For Clerk's Office Use Only COA: 42:0405id NOS: 864 COA: 42:1383 NOS: 863/864 COA: 42:0405wc NOS: 863 COA: 42:0405ww NOS: 863 IV. Please check one of the three options below, whichever is applicable to your case and fill in the appropriate blanks: If you were granted disability benefits but you disagree with the ONSET DATE, check this box, complete this section and proceed to section V. Plaintiff was found disabled by the Social Security Administration on ___ /___ / ___ . The plaintiff alleges that his/her disability began on ___ /___ / ___ (date of alleged onset of disabling condition). If you were granted disability benefits but these were LATER TERMINATED OR REDUCED, check this box, complete this section and proceed to section V. Plaintiff was found disabled by the Social Security Administration on ___ /___ / ___ . This disability was found to have begun on ___ /___ / ___ (date of disabling condition) and plaintiff was granted disability benefits which started on ___ /___ / ___ (date of first payment). Subsequently, plaintiff's benefits were (circle one) terminated / reduced, effective ___ /___ / ___ (date of termination or reduction in amount of payment). If your initial application for disability benefits was DENIED, check this box and proceed to section V. V. Following the Social Security Administration action identified in section IV above, plaintiff requested a hearing, and on ___ /___ / ___ (date of hearing), a hearing was held before an Administrative Law Judge which resulted in a denial of plaintiff's claim on ___ /___ / ___ (date of ALJ decision) or in a finding of a disability at a date later than plaintiff's claimed date of disability. Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Pro Se: SSA Complaint-Wyo VI. The decision of the Administrative Law Judge was referred to the Appeals Council and the decision was (check one): AFFIRMED REVERSED IN PART Date of decision: ___ /___ / ___. Plaintiff received the decision from the Appeals Council on ___ /___ / ___. You must attach a copy of the decision of the Appeals Council to this complaint. Failure to attach a copy of the decision of the Appeals Council may result in your complaint being dismissed for failure to exhaust your administrative remedies. VII. Plaintiff has exhausted administrative remedies in this matter and this court has jurisdiction for judicial review pursuant to 42 U.S.C § 405(g) and/or 1383(c)(3). WHEREFORE, plaintiff seeks judicial review by this court and the entry of a judgment for such relief as may be proper, including costs. VIII. Under Federal Rule of Civil Procedure 11, by signing below, I certify to the best of my knowledge, information, and belief that this complaint: (1) is not being presented for an improper purpose, such as to harass, cause unnecessary delay, or needlessly increase the cost of litigation; (2) is supported by existing law or by a nonfrivolous argument for extending or modifying existing law; (3) the factual contentions have evidentiary support or, if specifically so identified, will likely have evidentiary support after a reasonable opportunity for further investigation or discovery; and (4) the complaint otherwise complies with the requirements of Rule 11. I agree to provide the Clerk's Office with any changes to my address where case-related papers may be served. I understand that my failure to keep a current address on file with the Clerk's Office may result in the dismissal of my case. Plaintiff's Signature Dated Printed Name (Last, First, MI) Address Telephone Number City State E-mail Address (if available) Zip Code Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com