Borges v. Berryhill

Filing 4

ORDER signed by Judge J.P. Stadtmueller on 10/13/2017 DENYING without prejudice 2 Plaintiff's Motion for Leave to Proceed Without Prepayment of the Filing Fee. Within 14 days, Plaintiff to file: revised motion for leave to proceed without prepayment of the filing fee and an amended complaint utilizing the Court's Social Security complaint form. See Order. (Attachments: # 1 Social Security Complaint Form) (cc: all counsel, via mail to Lila Marie Borges) (jm)

INSTRUCTIONS FOR FILING A PRO SE COMPLAINT FOR REVIEW OF A FINAL
DECISION BY THE COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION
1.

You must fill out the complaint form in the space provided. Part II is the ONLY place you can
use extra space, as instructed, to describe any previous cases you have filed.

2.

Your complaint must be neatly printed or typed. You must sign the complaint, which states
under penalty of perjury that the facts you have stated are true. “Under penalty of perjury”
means that any false statement of a material fact may result in criminal penalties.

3.

Do not present arguments in the complaint. If the case proceeds, the Court will issue a schedule
for filing briefs that will allow you the opportunity to state your arguments.

4.

The cost of filing this case is $400.00, which includes a $350.00 filing fee and a $50.00
administrative fee. The full $400.00 cost is due when you file your complaint and can be paid
with a check or by credit card. A check should be made payable to “Clerk of Court.”

5.

If you cannot afford the filing fee, you may file a request to proceed without it. To do so,
complete and sign, under penalty of perjury, a request to proceed in district court without
prepaying the filing fee.

6.

You must file the original complaint with the Clerk of Court. Keep a copy of all papers you file
or receive in this case.

7.

MAIL OR BRING COMPLETED FORM(S) TO:
Clerk, United States District Court
Room 362 Federal Courthouse
517 E. Wisconsin Avenue
Milwaukee, WI 53202

8.

The Court will notify you by mail of everything that happens in your case, so you must provide
the address where you receive your mail. If that address changes, notify the Court of the new
address immediately.

9.

The Clerk of Court has a guide, Answers to Pro Se Litigants’ Common Questions, which may be
helpful if you have questions. Not everything covered in the guide will apply to your case. You
can pick up a copy in the Clerk’s Office, Room 362, Federal Courthouse, or call the Clerk’s
Office at [phone] and ask that one be mailed to you. The guide is also available at the
District Court’s website www.wied.uscourts.gov under Pro Se Resources.

10.

You may be able to get legal assistance from the Eastern District of Wisconsin Bar Association
Pro Se Federal Civil Litigant Help Line. Before a volunteer lawyer can help you, you must read
and sign an agreement form. You can pick up this form at the Clerk’s Office, Room 362, Federal
Courthouse, or you can call the Clerk’s Office at [phone] or the Eastern District of
Wisconsin Bar Association at [phone] and ask that a copy be mailed to you. You may
also complete the form online at www.edwba.org or by using the link to the helpline at
www.wied.uscourts.gov under Pro Se Resources.

Social Security Complaint – Pro Se Form

Revised 3/2016

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF WISCONSIN

________________________________
________________________________
________________________________
Plaintiff: your full name and the full
name of any person on whose behalf you
are filing this case; use initials instead
of the full name for a child under age 18.
v.

Case No. ______________________
(supplied by Clerk after case is filed)

Commissioner of the Social Security Administration,
Defendant.

COMPLAINT FOR REVIEW OF A FINAL DECISION BY THE COMMISSIONER OF THE
SOCIAL SECURITY ADMINISTRATION

I. Parties
A.

Plaintiff (your name): _____________________________________________________
If you are filing this case on behalf of someone else, include that person’s full name and

______________________________________________________________________________
relationship to you. Use initials instead of the full name for a child under age 18.

B.

The Social Security Number used by the Social Security Administration in this case:
________________________________________________________________________

C.

Your mailing address, including the county where you reside, and phone number (with area
code):
________________________________________________________________________
________________________________________________________________________

D.

Defendant:

Commissioner of the Social Security Administration
c/o Office of General Counsel, SSA
200 W. Adams Street, 30th Floor
Chicago, Illinois 60606-5208
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Social Security Complaint – Pro Se Form

Revised 3/2016

II. Previous Lawsuits
A.

Have you filed any other case in state or federal court related to the same facts involved
in this case?
YES

B.

Have you filed any other case in state or federal court, even if it was not related to the facts
involved in this case?
YES

C.

NO

NO

If your answer to A or B is YES, provide the requested information below. If you filed more
than one case, describe each additional case on a separate sheet of paper using the format
below. DO NOT USE THE BACK OF THIS FORM.
1. Parties to the previous case:
Plaintiff(s):

____________________________________________________________

Defendant(s): ____________________________________________________________
2. Court in which the case was filed (for federal courts, name the district; for state courts,
name the county):
________________________________________________________________________
3. Case number: __________________________________________________________
4. Current status (for example: open, closed, on appeal):
5. Approximate date the case was filed:

________________________

____________________________________

6. Approximate date the case ended: ____________________________________
III. Statement of Claim
A.

The type of Social Security benefits that you, or the person on whose behalf you are filing this
case, seek in this case (check all that apply):
Supplemental Security Income (SSI)
and/or
Disability Insurance (SSDI or Widow/Widower)
and/or
Other (explain):

______________________________________________________
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Social Security Complaint – Pro Se Form

Revised 3/2016

B.

I seek review of an unfavorable final decision of the Commissioner of the Social Security
Administration under 42 U.S.C. § 405(g) and/or 42 U.S.C. § 1383(c)(3).
I have received a decision from the Administrative Law Judge, and it is dated:
________________________________________________________________________
If you have a copy of the Administrative Law Judge’s decision, attach it to this complaint.

I have received an Appeals Council’s notice or determination, and it is dated:
________________________________________________________________________
If you have a copy of the Appeals Council’s notice or determination, attach it to this complaint.

I, or the person on whose behalf I am filing this case, was disabled during the time
period included in this case. I believe the Commissioner’s unfavorable conclusions and
findings of fact are not supported by substantial evidence; and/or are contrary to law and
regulation.
Use the space below to state any additional facts that may explain why you or the person on
whose behalf you are filing this case are/is entitled to relief. Use only the space provided
below—keep the facts short and to the point.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
IV. Relief Sought
I request all such relief as is proper under the Social Security Act and as the Court otherwise
deems appropriate, including costs.
I declare under penalty of perjury that the foregoing is true and correct.
Dated this _______________ day of ____________________, 20 __________.
_______________________________________________________________
Signature of Plaintiff/Legal Representative
Page 4 of 4
Social Security Complaint – Pro Se Form

Revised 3/2016