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Complaint For Judicial Review Of Decision Of The Commissioner Of Social Security - United States District Court Page 2

The final decision of the Commissioner was not based on substantial evidence in the record and

contains the following errors of law: (state each alleged error that entitles the Plaintiff to relief in

numbered paragraphs, beginning with 5).

5. _______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________.

Attach additional sheets of paper as necessary.

□

Check here if additional sheets of paper are attached:

Please continue to number the paragraphs consecutively.

REQUEST FOR RELIEF

The Plaintiff requests that the final decision of the Defendant be reversed for an award of benefits or,

alternatively, either modified or remanded for further proceedings.

SOCIAL SECURITY NUMBER

Pursuant to Local Rule 9.1, the wage earner's social security number has been attached to the copy of

the complaint served on the Commissioner of Social Security.

Date:_____________

______________________________________

Signature of Plaintiff

Mailing Address

_________________________________________

Telephone Number

_________________________________________

Complaint For Judicial Review Of Decision Of The Commissioner Of Social Security - United States District Court Page 2