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- Written by Salomone Donghwa Shin / International Legal Research Institute. www.ilri.co.kr
Complaint for Review of Social Security Decision
Form Number: Pro Se 13
Category: Civil Pro Se Forms
Effective onDecember 1, 2016
2022년 12월 1일 현재 미국 법원에서 사용중인 민사소송 Complaint for Review of Social Security Decision 서식입니다.
사회보장결정검토를 위한 이의제기서 Complaint for Review of Social Security Decision 는 장애혜택 disability benefits 청구 claim 에 있어 사회보장국(SSA)이 내린 결정 decision 에 비동의 disagree 하는 경우 청구인 a claimant 또는 그 대리인 representative 이 연방법원 federal court 에 제출할 수 있는 법적 문서입니다.
이의제기 complaint 는 청구인이 사회보장국 SSA의 최종결정 final decision 을 받은 후 60일 이내에 해야 하며 결정이 잘못되었다는 구체적인 이유를 제시해야 must provide specific reasons 합니다. 그러면 법원은 결정을 검토 review 해서 사회보장프로그램 Social Security program 에 적용되는 법률 law 및 규정 regulations 에 따라 결정이 내려졌는지 판단합니다.
사회보장결정검토를 위한 이의제기는 청구인이 사회보장국이 내린 결정에 이의를 제기하고 필요한 경우 연방법원에서 구제를 구할 수 있도록 하는 중요한 법적 도구입니다.
다음은 미국 대법원의 판례입니다.
1. Eldridge v. Weinberger(1974): 이 사건에서 대법원은 사회보장국 SSA 의 장애판정절차 disability determination process 를 합헌 constitutionality 으로 판결했고, 청구인 claimant 이 행정법 판사 administrative law judge 에게 심리할 기회와 연방법원에서 결정에 항소할 권한도 부여함.
2. Bowen v. Yuckert(1989): 이 사건은 SSA가 장애혜택을 부적절하게 거부했다는 원고의 청구에 대법원은 사회보장국 SSA의 결정이 실질적 증거에 의해 뒷받침 되었고 was supported by substantial evidence 청구인 claimant 이 장애가 있음을 입증할 책임을 다하지 못했다고 판결함.
3. Martinez v. Astrue(2010): 이 사건에서 정신장애 mental disability 가 있는 청구인 claimant 은 자신의 혜택을 거부한 행정법 판사가 자신의 사건의 모든 증거를 채택하지 않았다고 주장했고 대법원은 이에 동의해 추가 심리 further consideration 를 위해 사건을 사회보장국 SSA에 환송 remanded 판결함.
4. Sims v. Apfel(2001): 이 사건은 원고의 직업 관련 증거가 부족하여 a lack of vocational evidence SSA가 장애 혜택을 부적절하게 거부했다고 주장했고 법원은 이에 동의해 추가 심리 further consideration 를 위해 사건을 사회보장국 SSA에 환송 remanded 판결함.
각 국가의 법원들은 고유의 소송 서식을 사용하므로 더 추가되는 내용들이 있지만 기본적으로 요구하는 내용은 크게 다르지 않아서 다른 국가와 비슷한 사건일 경우 본 내용을 참고하시기 바랍니다.
소송이 필요한 국가의 현지 변호사와 상담이나 번역과 통역을 원하시면 이메일 info@ilri.co.kr 로 문의해 주시기 바랍니다.
Pro Se 13 (Rev. 12/16) Complaint for Review of a Social Security Disability or Supplemental Security Income Decision
UNITED STATES DISTRICT COURT
for the
__________ District of __________
__________ Division
Case No.
(to be filled in by the Clerk’s Office)
Plaintiff(s)
(Write the full name of each plaintiff who is filing this complaint.
If the names of all the plaintiffs cannot fit in the space above, please write “see attached” in the space and attach an additional page with the full list of names.)
-v-
Defendant
(Write the full name of the current Commissioner of the Social Security Administration. Do not include address 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.
I. The Parties to This Complaint
A. The Plaintiff(s)
Provide the information below for each 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 the 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)
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
ㅁ Disability Insurance Benefits Claim (Title II) COA: 42:0405id
NOS: 864
ㅁ Supplemental Security Income Claim (Title XVI) COA: 42:1383
NOS: 863/864
ㅁ Child Disability Claim COA: 42:0405wc
NOS: 863
ㅁ Widow or Widower Claim COA: 42:0405ww
NOS: 863
An appeal from a decision of the Commissioner must be filed within 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 was 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.)
’ 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):
ㅁ Issue a summons directing the defendant to appear before the court.
ㅁ Order the defendant to submit a certified copy of the transcript and record, including evidence upon which the findings and decision are based.
ㅁ Modify the defendant's decision and grant monthly maximum insurance benefits to the plaintiff, retroactive to the date of initial disability.
ㅁ In the alternative, remand to the defendant for reconsideration of the evidence.
ㅁ 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.
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
고도의 국제법 전문가 그룹 - 국제법률연구원
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