Pro Se 13 (Rev.10/16) Complaint for Review of a Social Security Disability or Supplemental Security Income Decision
United States District Court
for the
NORTHERN DISTRICT OF ALABAMA
________________________________________ }
Plaintiff, }
(Write your full name. No more than one plaintiff
}
may be named in a pro se complaint)
}
}
}
}
v. }
} Case No.:________________________
(to be filled in by the Clerk’s Office)
}
}
}
}
}
________________________________________
}
Defendant.
}
(Write the full name of the current Commissioner
}
of the Social Security Administration. Do not
}
include addresses here.
}
COMPLAINT FOR REVIEW OF A SOCIAL SECURITY
DISABILITY OR SUPPLEMENTAL SECURITY INCOME DECISION
NOTICE
Federal Rules of Civil Procedure 5.2 addresses the privacy and security concerns resulting from
public access to electronic court files. Under this rule, papers filed with the court should not
contain: an individual’s full social security number or full birth date; the full name of a person
known to be a minor; or a complete financial account number. A filing may include only: the
last four digits of a social security number; the year of an individual’s birth; a minor’s initials;
and the last four digits of a financial account number.
Except as noted in this form, plaintiff need not send exhibits, affidavits, grievance or witness
statements, or any other materials to the Clerk’s Office with this complaint.
In order for your complaint to be filed, it must be accompanied by the filing fee or an application
to proceed in forma pauperis.
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Pro Se General Complaint for a Civil Case (Rev.10/16)
I. The Parties to This Complaint
A. The Plaintiff
Provide the information below for the plaintiff named in the complaint. Attach
additional pages if needed.
Name
Street Address
City and County
State and Zip Code
Telephone Number
E-mail Address
Last Four Digits of Your Social Security Number
(Do not include full number)
B. The Defendant
Provide the information below for each defendant named in the complaint. Attach
additional pages if needed.
Defendant (The current Commissioner of the Social Security Administration)
Name
Street Address
City and County
State and Zip Code
(Regional Office of the Social Security Administration General Counsel)
Telephone Number
E-Mail Address (if known)
☐ Check here to receive electronic notice through the e-mail listed
above. By checking this box, the undersigned consents to electronic
service and waives the right to personal service by first class mail
pursuant to Federal Rule of Civil Procedure 5(b)(2), except with
regard to service of a summons and complaint. The Notice of
Electronic Filing will allow one free look at the document, and any
attached PDF may be printed and saved.
Date Participant Signature
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Pro Se General Complaint for a Civil Case (Rev.10/16)
II. Basis for Jurisdiction
This is an action seeking court review of a decision of the Commissioner of the Social
Security Administration. Jurisdiction for such proceedings can be based on two statutes.
If this complaint seeks review of a decision regarding Disability Insurance Benefits under
Title II of the Social Security Act, jurisdiction is proper under 42 U.S.C. § 405(g). If this
complaint seeks review of a decision regarding Supplemental Security Income under
Title XVI of the Social Security Act, jurisdiction is proper under 42 U.S.C. § 1383(c)(3).
Please check the type of claim you are filing.
Claim Type For Clerk’s Office Use Only
☐Disability Insurance Benefits Claim (Title II) COA: 42:0405id
NOS: 864
☐Supplemental Security Income Claim (Title XVI) COA: 42:1383
NOS: 863/864
☐Child Disability Claim COA: 42:0405wc
NOS: 863
☐Widow or Widower Claim COA: 42:0405ww
NOS: 863
An appeal from a decision of the Commissioner must be filed within sixty (60) days of
the date on which you received notice that the Commissioner’s decision became final.
When did you receive notice that the Commissioner’s decision was final? (This is likely
the date on which you received notice from the Social Security Appeals Council that your
appeal was denied.)
Please attach a copy of the Commissioner’s final decision, and a copy of the notice you
received that your appeal was denied from the Social Security Appeals Council.
III. Statement of Claim
Federal courts may overturn decisions by the Commissioner of Social Security only if the
decision is not supported by substantial evidence in the record or was based on legal
error. Why should this court overturn the Commissioner’s decision? (Check all that
apply)
☐ The Commissioner found the following facts to be true, but these facts are not
supported by substantial evidence in the record. (Explain why the Commissioner’s
factual findings are not supported by substantial evidence in the record.)
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Pro Se General Complaint for a Civil Case (Rev.10/16)
☐ The Commissioner’s decision was based on legal error. (Identify all legal errors)
IV. Relief
State what you want the court to do (check all that apply):
☐ Issue a summons directing the defendant to appear before the court.
☐ Order the defendant to submit a certified copy of the transcript and record,
including evidence upon which the findings and decision are based.
☐ Modify the defendant’s decision and grant monthly maximum insurance benefits
to the plaintiff, retroactive to the date of initial disability.
☐ In the alternative, remand to the defendant for reconsideration of the evidence.
☐ Grant any further relief as may be just and proper under the circumstances of this
case.
V. Certification and closing
Under Federal Rule of Civil Procedure 11, by signing below, I certify to the best of my
knowledge, information, and belief that this complaint: (1) is not being presented for an
improper purpose, such as to harass, cause unnecessary delay, or needlessly increase the
cost of litigation; (2) is supported by existing law or by a nonfrivolous argument for
extending, modifying, or reversing existing law; (3) the factual contentions have
evidentiary support or, if specifically so identified, will likely have evidentiary support
after a reasonable opportunity for further investigation or discovery; and (4) the
complaint otherwise complies with the requirements of Rule 11.
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Pro Se General Complaint for a Civil Case (Rev.10/16)
A. For Parties Without an Attorney
I agree to provide the Clerk’s Office with any changes to my address where case-
related papers may be served. I understand that my failure to keep a current
address on file with the Clerk’s Office may result in the dismissal of my case.
Date of Signing:
Signature of Plaintiff:
Printed Name of Plaintiff:
B. For Attorneys
Date of Signing:
Signature of Attorney:
Printed Name of Attorney:
Bar Number:
Name of Law Firm:
Street Address:
State and Zip Code:
Telephone Number:
E-mail Address:
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