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 defendant,
one for the United States Attorney, and
one for the United States Attorney General.
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:
(b) Print "Secretary of Department of Health and Human Services" as defendant;
(c) Since you do not have an attorney, print:
(2) "Pro Se" and
(3) your address
in the line following, "You are hereby summoned and requested to serve upon..."
(e) Put "90" in the space before "days after service of this summons".
(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:
(2) if your claim is for Supplemental Security Income, check Box No. 864: SSID Title XVI.
(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.
(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:
(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";
(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.
