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UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF OHIO ____________ DIVISION ________________________, Plaintiff vs. COMMISSIONER OF SOCIAL SECURITY, Defendant COMPLAINT The above named plaintiff makes the following representations to this court for the purpose of obtaining judicial review of a decision of the defendant adverse to the plaintiff. 1. The plaintiff is a resident of _____________________, _______________. (City) (State) Plaintiff's last four digits of their Social Security Account No. are ________. The plaintiff complains of a decision which adversely affects the plaintiff in whole or in part. The decision has become the final decision of the Secretary for purposes of judicial review and bears the following caption: IN THE CASE OF __________________________ (Claimant) (If Minor Child-only use initials) __________________________ (Wage Earner) 3. CLAIM FOR ____________________________ CASE NO. ____________________ 2. ________________________________ (Last Four Digits of Social Security No.) The plaintiff has exhausted administrative remedies in this matter and this court has jurisdiction for judicial review pursuant to 42 U.S.C. § 405 (g). Wherefore, plaintiff seeks judicial review by this court and the entry of judgment for such relief as may be proper, including costs. _____________________________ Plaintiff Date_____________________ _____________________________ Street Address _____________________________ City State Zip _____________________________ Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com