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Pro Se Social Security Complaint - Indiana
| Pro Se Social Security Complaint Form. This is a Indiana form and can be used in Southern District District Court Federal . |
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UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF INDIANA INDIANAPOLIS DIVISION ) ) ) ) ) ) ) ) ) ) Plaintiff, vs. CAROLYN W. COLVIN, Commissioner of the Social Security Administration Defendant. Cause No. COMPLAINT Comes now the plaintiff and for cause of action says the following: 1. The plaintiff resides within the Southern District of Indiana. 2. This is an action to review a final decision of the defendant Secretary of Health and Human Services. This Court has jurisdiction over the action pursuant to Section 205(g) of the Social Security Act, as amended, 42 U.S.C. ยง 405(g). 3. The plaintiff has previously filed application(s) for disability benefits and/or supplemental security income with the defendant and after various proceedings has been denied benefits. 4. a. The decision of the defendant Secretary is not supported by substantial evidence and should be reversed. For Court Use: NOS: 865 COA: 42:405id American LegalNet, Inc. www.FormsWorkFlow.com b. In addition, there were errors of law which require that the decision be reversed, namely, that _____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________. WHEREFORE, the plaintiff prays that the final decision of the Secretary be reviewed and set aside, that the plaintiff be awarded benefits as previously sought and that the plaintiff be awarded all other relief found just and proper. ___________________________________ (Signature of Plaintiff) _____________________________ Date _____________________________ (Print name) __________________________ (Street Address) ___________________________ (City, State, ZIP) ____________________________ (Telephone Number) For Court Use: NOS: 865 COA: 42:405id American LegalNet, Inc. www.FormsWorkFlow.com
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