Home About Contact |
Icon-UpArrow Item 13.03 (USNYWD Pro Se Handbook)
LogoAdobe Download
LogoAdobe Cover Sheet
LogoAdobe Indigence
LogoAdobe Summons


The special packet for Social Security Appeals may be obtained in person from the intake clerk in the Clerk’s Office, by mail from the Pro Se Office, and from the Western District Court web site at http://www.nywd.uscourts.gov.

Please be sure to read the privacy information discussed earlier regarding what should not be included in your appeal papers.

Fill out the complaint form completely, supplying all requested information in the spaces provided, especially the dates of final decisions by the Social Security Appeals Council. You will need to submit a total of four copies of the complaint:

one for the Court,
one for the defendant,
one for the United States Attorney, and
one for the United States Attorney General.

Be sure to sign the complaint. Keep one copy for your own personal file.

Attach copies of the Social Security Appeals Council decision and the Office of Hearings and Appeals decision to each copy of the complaint. Be sure to provide all docket numbers and courts of any prior federal cases.

Fill out the "Summons for a Civil Action" (one original and four copies) as follows:

(a) Print your name as plaintiff;

(b) Print "Secretary of Department of Health and Human Services" as defendant;

(c) Since you do not have an attorney, print:
(1) your own name;
(2) "Pro Se" and
(3) your address

in the line following, "You are hereby summoned and requested to serve upon..."

(d) Cross out "Plaintiff's Attorney"; and

(e) Put "90" in the space before "days after service of this summons".

Fill out the "Civil Cover Sheet" according to these instructions:

(a) Print your name as Plaintiff;

(b) Print "Secretary of Health and Human Services" as Defendant;

(c) Print "Pro Se" under Plaintiff's Attorney;

(d) Put "United States Attorney, Buffalo, New York" as Defendant's Attorney;

(e) Basis for Jurisdiction: check Box No. 2: U.S. Defendant;

(f) Citizenship of Principal Parties: leave blank;

(g) Cause of Action: "42 U.S.C. §405(g)" and "Judicial Review of Social Security Administrative Decision";

(h) Nature of Suit:

(1) if your claim is for Social Security Disability, check Box No. 863: DIWW;

(2) if your claim is for Supplemental Security Income, check Box No. 864: SSID Title XVI.

(i) Origin: check Box No. 1: Original Proceeding;

(j) Requested in Complaint: leave blank;

(k) Related Case(s) if any: if you have ever filed another federal lawsuit relating to social security benefits, write the name of the court and the docket number; and

(l) Date and sign your name followed by "Pro Se" on the last line.

Fill out the three United States Marshal's forms according to these instructions. Do not make any entries other than those indicated below:

(a) Do not detach or remove any of the copies from this form;

(b) Plaintiff: print or type your name;

(c) Defendant: print or type "Secretary of Department of Health and Human Services";

(d) Court number: leave blank

(e) To the right of the large black arrow:

(1) on one form, print or type "Office of General Counsel, Social Security Administration, Room 611 Altmeyer, 6401 Security Boulevard, Baltimore, MD 21235"

(2) on the second form, print or type "Attorney General of the United States, Main Justice Building, 10th and Constitution Avenues NW, Washington, DC 20530"

(3) on the third form, print or type "United States Attorney, 138 Delaware Avenue, Buffalo, NY 14202";

(f) Type of writ: print or type "Summons and Complaint";

(g) In block marked "Send Notice of Service Copy to Name and Address below", print or type your name and address; and

(h) In block marked "Name and Signature of Attorney or Other Originator", sign your name, followed by "Pro Se", provide your telephone number and date the form.

IMPORTANT: If you cannot pay the filing fee and are applying for permission to proceed as a poor person, no papers will be served upon the defendants until the District Judge has granted you permission to proceed as a poor person and directed the United States Marshal to serve the complaint. (US District Court, New York, Western District // Buffalo, NY 14202 // Pro Se Litigation Guidelines)
Congratulations! You're now booked up on Item 13.03 from USNYWD's Pro Se Handbook!

Please get the justice you deserve.


add a comment
IconQuiz IconLike
Icon-Email-WBIcon-Email-WG Icon-Youtube-WBIcon-Youtube-WG Icon-Share-WBIcon-Share-WG
Pages You Might Also Like