Fill and Sign the Appeals Decision Form

IN THE UNITED STATES DISTRICT COURT FOR THE ____________ DISTRICT OF ___________ ___________________ DIVISION NAME OF PLAINTIFF ) SOCIAL SECURITY NO.__________________       ) ) V. ) NO.       ) ) NAME OF DEFENDANT )       ) COMMISSIONER OF SOCIAL SECURITY ) ) COMPLAINT The plaintiff, _____________, is an actual, bona fide, adult, resident citizen of ________ County, ___________, and shows the Court that the defendant is ___________, COMMISSIONER OF SOCIAL SECURITY. This proceeding is brought pursuant to Section 205(g) of the Social Security Act as amended by Section 405(g), Title 42, United States Code, and all laws amendatory and supplementary thereto. Plaintiff was a party to a claim pending before the Social Security Administration, and a Final Decision was reached by the Appeals Council on ___________ __, ____, as shown by a true and correct copy of said decision which is hereto attached and marked Exhibit "A" and made a part of this Complaint the same as if copied at length herein in words, figures and symbols alike. The said decision was a final decision by said body and defendant, and the plaintiff charges that it is erroneous and denies benefits for which the plaintiff is entitled to receive, and is erroneous in that it deprives her of receiving her social security disability insurance benefits for which she is entitled to receive as shown by her application and by the entire record in this matter, and this appeal is made within sixty (60) days from the date of the decision of the Appeals Council. The plaintiff further shows unto the Court that the Appeals Council could not have fully considered her claim in that deciding the issues, the Appeals Council did not have the record before it, and did not see the evidence, nor read the testimony of the witnesses. Plaintiff demands that defendant file a certified copy of the entire transcript and record in her case on file with them as required by law, and requests a reversal of the decision and that the Department of Health and Human Services be required to pay the plaintiff the total benefits she is entitled to receive by law; and she prays for all other relief as she may be entitled to receive under the law and equity and as in duty bound will she ever pray. Respectfully submitted, ____________________________