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Social Security Complaint - Indiana
| Social Security Complaint Form. This is a Indiana form and can be used in Northern District District Court Federal . |
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FOR USE IN PETITIONING FOR REVIEW OF DECISION OF SOCIAL SECURITY ADMINISTRATION IN THE UNITED STATE DISTRICT COURT NORTHERN DISTRICT OF INDIANA ) ) ) Plaintiff, ) ) v. ) ) SOCIAL SECURITY ADMINISTRATION ) Defendant. ) CASE NO. COMPLAINT Comes now the plaintiff and alleges as follows: COUNT I 1. 2. This court has jurisdiction to hear this cause pursuant to 42 U.S.C. ยง405(g). The plaintiff name of plaintiff . City and State 3. 4. 5. 6. 7. 8. 9. The defendant is the Social Security Administration. The plaintiff's Social Security number is The plaintiff is or has been fully insured under the Social Security Act. The plaintiff filed an application for social security disability insurance benefits. This request or these requests were denied. The final administrative decision was rendered on decision of Appeals Council). The plaintiff has exhausted all administrative remedies. (date of . , is a resident of American LegalNet, Inc. www.USCourtForms.com 10. The Commissioner's decision to deny the plaintiff's application was erroneous and was not supported by substantial evidence in the administrative record. This contention may be set forth more fully in the space that follows: WHEREFORE, the plaintiff requests that the court reverse the decision of the Commissioner and order the Commissioner to pay to the plaintiff Social Security Disability Insurance Benefits, the costs of this action and, as applicable, supplemental income. The plaintiff further requests all other relief that the court may deem just and proper. Further requests for relief may be set forth more fully on page 3 of this form. Signature of plaintiff Typed or printed name Street address City State Zip Code ________________________________________ Telephone number (including area code) 2 American LegalNet, Inc. www.USCourtForms.com FURTHER STATEMENT OF BASIS FOR CLAIM (Optional) FURTHER REQUEST FOR RELIEF (Optional) AFFIRMATION OF PLAINTIFF 1. I, , the plaintiff in the aforementioned cause, do affirm that I have read all of the statements contained in the complaint and those which are attached in the accompanying financial statement. I believe them to be, to the best of my personal knowledge, true and correct. 2. Moreover, while neither the complaint or the financial affidavit has been notarized, I do understand that this complaint and these affidavits will become an official part of the United States District Court files and that ANY false statements knowingly made by me are illegal and may subject me to criminal penalties. Signature of Plaintiff DATE: 3 American LegalNet, Inc. www.USCourtForms.com
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