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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,
V.
COMPLAINT FOR REVIEW OF THE DECISION
OF THE COMMISSIONER OF SOCIAL
SECURITY
MICHAEL J. ASTRUE, Commissioner of Social Security, Defendant.
CIVIL ACTION
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): _________________________________________
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. ยง 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