I-4-1-111.Exhibit - Fill-in Draft Declaration-Failure to Exhaust (DCL 12)

Last Update: 9/13/05 (Transmittal I-4-15)

IN THE UNITED STATES DISTRICT COURT
FOR THE [N / E / W / S / M / C] DISTRICT OF [STATE]
[DIVISION]

[CLAIMANT'S NAME]

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[SSN]

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Plaintiff

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vs.

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CIVIL ACTION NO. [Number]

 

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[COMMISSIONER'S NAME]

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COMMISSIONER OF

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SOCIAL SECURITY

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Defendant

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DECLARATION OF [BRANCH CHIEF NAME]
COURT CASE PREPARATION AND REVIEW BRANCH [Number]
OFFICE OF HEARINGS AND APPEALS

SOCIAL SECURITY ADMINISTRATION

{2}

I, [System copies BRANCH CHIEF NAME from {1}], [Acting] Chief of Court Case Preparation and Review Branch [System copies Branch Number from {1}] of the Office of Appellate Operations, Office of Hearings and Appeals, Social Security Administration, declare and state as follows:

{3}

(1) Under direct delegation from the Commissioner of Social Security, the Office of Hearings and Appeals administers a nationwide hearings and appeals program. The Office of Hearings and Appeals includes the Appeals Council and Administrative Law Judges who hold hearings on claims arising under [Title II / Title XVI / Titles II and XVI] of the Social Security Act, as amended, when such hearing is duly requested by a claimant who is dissatisfied with the administrative determination of a claim. The Office of Appellate Operations provides professional and technical advice to the Associate Commissioner and Administrative Appeals Judges of the Appeals Council in the processing of cases in which a civil action has been filed.

{4}

(2) One function of the Appeals Council is to act on requests for review of hearing decisions made by Administrative Law Judges and to either grant, deny or dismiss any such request. Under the regulations of the Social Security Administration, if the Appeals Council denies a timely request for review of a hearing decision, that hearing decision becomes the “final decision” within the meaning of, and subject to, the provisions for judicial review in section 205(g) of the Social Security Act, as amended (42 U.S.C. section 405(g)), the first sentence of which reads as follows:

“Any individual, after any final decision of the Commissioner made after a hearing to which he was a party, irrespective of the amount in controversy, may obtain a review of such decision by a civil action commenced within sixty days after the mailing to him of notice of such decision or within such further time as the Commissioner may allow.***”

{5}

(3) I am responsible for the processing of claims under [System copies Title from {3}] of the Social Security Act, as amended, whenever a civil action has been filed in the State of [System copies State from {1}]. The official file maintained by the Office of Hearings and Appeals relating to the claim of the plaintiff, [CLAIMANT'S NAME], under [System copies Title from {3}] of the Social Security Act, is presently within my custody and has been examined under my supervision. To the best of my knowledge and belief said file shows that:

{6}

(a) [User keys in sufficient information regarding the procedural history of the case to make it clear that the claimant had not yet completed all required steps in the administrative process prior to filing a civil action.]

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In accordance with 28 U.S.C. §1746, I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge and belief.

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___________________ Date

________________________________________ [BRANCH CHIEF NAME]