I-4-1-110.Exhibit - Documentation of Civil Action Filing Date Memo for File

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

DOCUMENTATION OF CIVIL ACTION FILING DATE

OFFICE OF HEARINGS AND APPEALS

MEMORANDUM FOR THE FILE

________________________

Date

_______________________

Claimant's Name

________________________

Civil Action Number

_______________________

Wage Earner

________________________

Court's Phone Number

_______________________

Social Security Number

____________________________________________________

Contact with the Office of the Clerk, United States District Court for the
____________________ District of ___________________

Person called: __________________________ Person's Title: ____________________

A civil action was filed on ______________________________

If in forma pauperis,
       petition filed on ___________________ and granted on ____________________

____________________________
Civil Action Assistant