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Social Security Complaint - Connecticut
| Social Security Complaint Form. This is a Connecticut form and can be used in District Court Federal . |
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UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT (Name) Plaintiff, v. Case No. (To be supplied by the Court) COMMISSIONER OF SOCIAL SECURITY, Defendant SOCIAL SECURITY COMPLAINT 1. This is an action seeking court review of a decision of the Commissioner of the Social Security Administration, pursuant to Section 205(g) of the Social Security Act, as amended, 42 U.S.C. § 405(g). 2. Plaintiff resides at the following location: 3. Defendant is the Commissioner of Social Security, and as such has full power and responsibility over disability benefits under the Social Security Act. 4. Check the type of claim you are filing: _____ Social Security Disability Claim _____ Supplemental Security Income Claim _____ Child Disability Claim _____ Widow or Widower Claim Rev. 11/14/11 American LegalNet, Inc. www.FormsWorkFlow.com 5. years: List all social security cases you have filed in this court in the last ten (10) _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 6. Plaintiff should have been entitled to receive (or should continue to receive) disability benefits (disability income benefits and/or supplemental security income benefits) because of the following disability This disability began on (give date) 7. . CIRCLE LETTER A, B or C, WHICHEVER IS APPLICABLE TO YOUR CASE, AND FILL IN THE APPROPRIATE BLANKS: A. If you were granted disability benefits but you disagree with the ONSET DATE, circle letter A, complete this section and proceed to Question 8. 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). B. If you were granted disability benefits but these were LATER TERMINATED OR REDUCED, circle letter B, complete this section and proceed to Question 8. Rev. 11/14/11 2 American LegalNet, Inc. www.FormsWorkFlow.com 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). C. If your initial application for disability benefits was DENIED, circle C and proceed to Question 8. 8. Following the Social Security Administration action identified in A, B or C above, plaintiff requested a hearing, and on _______________________ (date), a hearing was held before an Administrative Law Judge which resulted in a denial of plaintiff's claim on ________________ (date) or in a finding of disability at a date later than plaintiff's claimed date of disability. 9. The decision of the Administrative Law Judge was referred to the Appeals Council and the decision was (circle one) AFFIRMED / REVERSED IN PART on _____________________ (date). Plaintiff received the decision from the Appeals Council on _______________________ (date). 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. Rev. 11/14/11 3 American LegalNet, Inc. www.FormsWorkFlow.com 10. The decision of the Administrative Law Judge, as affirmed by the Appeals Council if your case was referred, was wrong, not supported by substantial evidence on the record, or contrary to law because _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ____________________________ 11. WHEREFORE, Plaintiff prays that: a. Defendant be required to answer this complaint and file a certified copy of the transcript of the record, including evidence upon which the findings and decision complained of are based; b. Upon this record, the district court should review, revise and set aside the decision of the defendant to grant maximum monthly disability benefits to the plaintiff, retroactive to the date of initial disability; or supplemental security income benefits, retroactive to the date of application, or, in the alternative, remand to the Commissioner for further administrative proceedings; and c. of this case. For such further relief as may be just and proper under the circumstances _____________________________ Original signature of attorney (if any) ______________________________ Plaintiff's Original Signature ______________________________ Rev. 11/14/11 4 American LegalNet, Inc. www.FormsWorkFlow.com Printed Name Printed Name Attorney's full address and telephone Plaintiff's full address and telephone Email address if available Dated: Email address if available DECLARATION UNDER PENALTY OF PERJURY The undersigned declares under penalty of perjury that he/she is the plaintiff in the above action, that he/she has read the above complaint and that the information contained in the complaint is true and correct. 28 U.S.C. § 1746; 18 U.S.C. § 1621. Executed at _________________________ on ________________________. (location) (date) ________________________________ Plaintiff's Original Signature Rev. 11/14/11 5 American LegalNet, Inc. www.FormsWorkFlow.com
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