Fill and Sign the Entered and Ordered Department of Justice Form

IN THE UNITED STATES DISTRICT COURT FOR THE ____________ DISTRICT OF ___________ ___________________ DIVISION NAME OF PLAINTIFF)SOCIAL SECURITY NUMBER )) V. )NO. ))NAME OF DEFENDANT) )ACTING COMMISSIONER OF ___________________________)) COMPLAINT The Plaintiff, complaining of the Defendant, would respectfully show the Court that: I. The Plaintiff is a citizen and resident of the _____________ and of the County of _________, State of _______________; that jurisdiction of this Court is founded as provided by Section 205 (g) of the Social Security Act, as amended, Section 405(g), Title 42, United States Code, and by Section 163C (3) of said Act, and Section 1383C (3), Title 42 United States Code. II. An application was filed by the Plaintiff with the Commissioner, the Social Security. Administration; that said application was filed by the above named Plaintiff to establish his entitlements for a period of disability in accordance with the laws of the United States of America. That this matter was heard before an Administrative Law Judge who ruled on ___________ __, ____ that the Plaintiff was not entitled to a period of disability. That on the ______ day of ________, _____ a subsequent denial of the Plaintiff's request for review was issued by the Appeals Council. III. The Plaintiff has exhausted Administrative remedies and the Defendant has issued its final Administrative decision. IV. In reaching its Administrative decision that the Plaintiff was not entitled to disability benefits, the Defendant applied improper legal standards. In addition, the Administrative decision of the Defendant is not supported by substantial evidence. For these reasons, the Plaintiff seeks Judicial Review of the Final Administrative Decision of the Defendant pursuant to Section 216(I) and Section 223 of the Social Security Act, Title 42, United States Code, and a determination that: (1) The final administrative decision of the Defendant is erroneous; and, (2) an award of benefits consistent with the provisions of the Social Security Act. WHEREFORE, the Plaintiff prays for Judicial Review of the Final Administrative determination of the Defendant and an award of a period of disability and disability benefits and Supplemental Security Income commencing on ____________ __, ____. Respectfully submitted, ______________________________