CONFIDENTIAL INFORMATION
THIS DOCUMENT MUST BE SERVED ON THE GOVERNMENT ALONG WITH THE SUMMONS AND COMPLAINT. IT IS NOT TO BE FILED WITH THE COURT. IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND _____________________________ vs. COMMISSIONER, SOCIAL SECURITY : : : CIVIL ACTION NO. _______________
STATEMENT OF SOCIAL SECURITY NUMBER
Social Security Number of Claimant:
Social Security Number of Worker (if different than claimant):
_____________ (Date)
________________________________________________ (Signature) ________________________________________________ ________________________________________________ ________________________________________________