B. Social Security Appeals
C. Title VII Employment Discrimination Claims
USNYWD's Pro Se Handbook
Chapter 13
Instructions for Forms Used for Filing Specific Cases
13.01 | INTRO - FILING SPECIFIC CASES
B. Social Security Appeals
C. Title VII Employment Discrimination Claims
13.02 | HABEAS CORPUS PETITIONS
PETITION UNDER 28 U.S.C. §2254 FOR WRIT OF HABEAS CORPUS BY A PERSON IN STATE CUSTODY
NOTE: If you are attacking a judgment which imposed a sentence to be served in the future, you must fill in the name of the state where the judgment was entered. If you have a sentence to be served in the future under a federal judgment which you wish to attack, you should file a motion under 28 U.S.C. §2255 in the federal court which entered the judgment. Check the Western District’s web site at www.nywd.uscourts.gov for copies of many of the Court’s forms and other useful information.INSTRUCTIONS - READ CAREFULLY
(2) Additional pages are not permitted except with respect to the facts which you rely upon to support your grounds for relief. No citation of authorities need be furnished. If briefs or arguments are submitted, they should be submitted in the form of a separate memorandum.
(3) Upon receipt of a fee of $5.00, your petition will be filed if it is in proper order.
(4) If you do not have the necessary funds for transcripts, counsel, appeal, and other costs connected with a motion of this type, you may request permission to proceed in forma pauperis, in which event you must execute the Court's form motion to proceed in forma pauperis, setting forth information establishing your inability to pay the costs. If you wish to proceed in forma pauperis, you must have an authorized officer at the penal institution complete the certificate as to the amount of money and securities on deposit to your credit in any account in the institution.
(5) Only judgments entered by one court may be challenged in a single motion. If you seek to challenge judgments entered by different courts either in the same state or in different states, you must file separate petitions as to each court.
(6) You must include all grounds for relief and all facts supporting such grounds for relief in the petition you file. You may not be permitted the opportunity to raise any claim in a second or successive habeas corpus application that was not presented in the original habeas corpus application. 28 U.S.C. §2254(e).
(7) A one-year statute of limitations applies to an application for a writ of habeas corpus; the limitations period runs from the latest of several different points in time, so you must check the statute to see which date applies to your petition. 28 U.S.C. §2244(d)(1).
(8) When the petition is fully completed, the original and at least two copies must be mailed to the Clerk of the United States District Court at one of the following addresses:
| Buffalo Division: | Rochester Division: |
|---|---|
|
200 U.S. Courthouse 2 Niagara Square Buffalo, New York 14202 (716) 551-1500 or (716) 551-1700 |
2120 United States Courthouse 100 State Street Rochester, New York 14614-1387 (585) 613-4000 |
13.03 | SOCIAL SECURITY APPEALS
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.
13.04 | TITLE VII EMPLOYMENT DISCRIMINATION CLAIMS
b) Notice of Right to Sue letter from the EEOC (make sure you include the date of the letter in the proper place on the complaint form)
c) Determination made by the EEOC on your charge filed there
(b) Print all defendants as Defendants
(c) Print "Pro Se" under Plaintiff's Attorney
(d) Leave Defendant's Attorney blank
(e) Basis for Jurisdiction:
(h) Origin:
(j) Date, and sign your name, followed by "Pro Se" on the last line.
Requests for assigned counsel may be made pursuant to 42 U.S.C. Section 2000e-5(f)(1). However, assignment of counsel is within the discretion of the judge and will generally only be made where the judge believes a lawyer is necessary.
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.
You might need to reference it during your pursuit of justice.
For instance, you might need to examine one of these passages in order to protect yourself from organizations/judges/lawyers who break the law (see this example of a Florida judge who outright committed perjury).
Nevertheless – and as always – please get the justice you deserve.
Sincerely,
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