I-4-1-94.Exhibit - Standard Certification Form

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

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

[Claimant 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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CERTIFICATION

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The undersigned, as [Acting] Chief, Court Case Preparation and Review Branch [Number], Office of Appellate Operations, Office of Hearings and Appeals, Social Security Administration, hereby certifies that the documents annexed hereto constitute a full and accurate transcript of the entire record of proceedings relating to this case.

 

 

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[BRANCH CHIEF NAME]       

Date: [System-generated]