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Complaint - Social Security Commissioner - Maryland
| Complaint - Social Security Commissioner Form. This is a Maryland form and can be used in General District Court Federal . |
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APPENDIX A IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND _____________________________ _____________________________ _____________________________ vs. COMMISSIONER, SOCIAL SECURITY : : : : : CIVIL ACTION NO. _______________ COMPLAINT l. Plaintiff is a resident of ________________________________________________. (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: _____________________________ (Claimant) _____________________________ (Wage Earner if Different from Claimant) 3. 4. The date of the final decision by the Secretary against plaintiff is ______________. Plaintiff claims that the final decision of the Secretary is erroneous as a matter of CLAIM FOR: ____________________________ (Type of benefits) fact and as 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) ________________________________________________ ________________________________________________ ________________________________________________ (Printed name, address, and phone number of Plaintiff) American LegalNet, Inc. www.FormsWorkflow.com
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