UNITED STATES DISTRICT COURT WESTERN DISTRICT OF MICHIGAN NORTHERN DIVISION
, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant. / Case No.
Judge
The above-named plaintiff makes the following representations to this court for the purpose of obtaining judicial review of a decision of the defendant adverse to the plaintiff: 1. The plaintiff (whose Social Security Account number is resident of County State ) is a .
2. The plaintiff complains of a decision which adversely affects the plaintiff in whole or part. The decision has become the final decision of the Secretary for pur poses of judicial review and bears the following caption: In the case of: Claim for:
Claimant Wage Earner
Type of Benefit Social Security Number
3. The plaintiff has exhausted administrative remedies in this matter and this court has jurisdiction for judicial r eview pursuant to 42 U. S.C. ยง 405(g). WHEREF ORE plaintiff seeks judicial review by this court and the entry of a judgment for such relief as may be proper, including costs.
Attorney/Plaintiff's Signature
Address
Telephone Date:
5/95