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]
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[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 (except as designated on the Index herein) of the entire record of proceedings relating to this case.
[System generates graphic image of signature OR, if Acting, leaves blank]
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[BRANCH CHIEF NAME]
Date: [System-generated]