Maryland > Federal > District Court > Pro Se
Complaint For Appealing Denial Of Social Security Benefits - Maryland
| Complaint For Appealing Denial Of Social Security Benefits Form. This is a Maryland form and can be used in Pro Se District Court Federal . |
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IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND _____________________________ : _____________________________ : _____________________________ : vs. : CIVIL ACTION NO. _______________COMMISSIONER, SOCIAL SECURITY : COMPLAINT l. Plaintiff (whose Social Security Number is _________________________) is a residentof ____________________________________________________________________. (Provide your City or County and State of residence) 2. Plaintiff complains of a decision against him/her bearing the following caption: IN THE CASE OF: CLAIM FOR: _____________________________ ____________________________ (Claimant) (Type of benefits) _____________________________ ___________________________ (Wage Earner) (Social Security Number) 3. The date of the final decision by the Secretary against plaintiff is ______________. 4. Plaintiff claims that the final decision of the Secretary is erroneous as a matter of fact andas a matter of law. WHEREFORE plaintiff seeks judicial review by this Court pursuant to 42 U.S.C. Section 405(g), and entry of judgment for such relief as may be proper, including costs._____________ ________________________________________________(Date) (Signature) ________________________________________________ ________________________________________________ ________________________________________________Rev. 6/2000
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