TN 44 (11-23)
NL 00725.130 “ATY” UTIs – Attorney Fee
Information About Representatives Fees
How To Ask Us To Review the (1)
Fill-in:
(1) “Determination On The Fee Amount”/“Determination
On The Fee Agreement”
Information About Past-Due Benefits Withheld To Pay A Representative
ATY052 Attorney or Eligible Representative Not Registered with SSA
We withhold past-due benefits if the representative is a (1) and registers with us to receive direct fee payment. Although your representative
is a (2) , he or she did not register for direct payment before we completed our work on your
claim. For that reason, we did not withhold from your past-due benefits to pay the
fee we approve. Therefore, the Social Security Administration is not involved in paying
the fee. This is a matter between (3) and the (4) .
Fill-ins:
(1) lawyer/participant in the non-attorney direct payment demonstration project
(2) lawyer/participant in the demonstration project
(3) first and last name of number holder/you
(4) “lawyer”/“representative”
ATYR01 Attorney Fee Withheld and Paid to Lawyer
We took (1) out of (2) first check. We are paying this money to the lawyer who helped with this Social Security
claim.
Fill-ins:
(1) attorney fee amount *
(2) SN
(*) indicates that the fill-in is manual
ATYR02 Fee Amount Unknown – Past-Due Benefits Unknown
We base the amount of (1) fee on past-due benefits, if any. As soon as we (2) determine the amount of benefits, we will tell you the amount of the fee (3) can charge.
Fill-ins:
(1) “your attorney's”/“your representative's”/“the attorney's”/“the representative's”
(2) “make a decision on your spouse's/family's/child's/children's/null
claim” *
(3) “your attorney”/“your representative”/“the attorney”/“the representative”
(*) indicates that the fill-ins are manual
ATY002 Attorney Involved - Petition
When a lawyer wants to charge for helping with a Social Security claim, we must first
approve the fee. We usually withhold 25 percent of past due benefits in order to pay
for approved lawyer's fee.
ATYR03 Fee Agreement Subsequently Disapproved and No Past Due Benefits are Available
We wrote you before and said we had approved the fee agreement between (1) and the (2) . We also said we would tell (3) and the (4) the amount of the fee he or she can charge (5) .
We base the fee amount we allow under a fee agreement on (6) past-due benefits. There are no past-due benefits. Therefore, we no longer approve
the fee agreement between (7) and the (8) .
Even though we no longer approve the fee agreement, the (9) can still charge a fee for his or her services. If the (10) wants to charge a fee, he or she must ask us in writing to approve the fee. The (11) must give (12) a copy of his or her fee request and each attachment to the request. If the (13) does not want to charge a fee, he or she should tell us.
Fill-ins:
(1) Manual fill-in 1 input name of beneficiary who actually hired the attorney or
representative*
(2) “lawyer”/“representative”
(3) Ms. plus BLN/Mr. plus BLN/BGN/BGN plus BLN/“you”
(4) “lawyer”/“representative”
(5) Ms. plus BLN/Mr plus BLN/BGN/BGN plus BLN
(6) “her”/ “his”/ “your”
(7) Manual fill-in 2 input name of beneficiary who actually hired the attorney or
representative*
(8) “lawyer”/“representative”
(9) “lawyer”/“representative”
(10) “lawyer”/“representative”
(11) “lawyer”/“representative”
(12) “her”/ “him”/ “you”
(13) “lawyer”/“representative”
(*) indicates that the fill-in is manual
ATY003 Attorney Fees Withheld - Petition
Because a lawyer (1) with this claim, we withheld (2) from (3) (4) check.
Fill-ins:
(1) “helped”/“may have helped”
(2) amount withheld
(3) “your”/“her”/“his”
(4) “first”
ATYR04 Notify a Beneficiary with a Lawyer or Representative Eligible for Direct Payment that
Fee Authorization Cannot Be Released at the Time of Effectuation. (Additional Information
Pending)
When a (1) wants to charge for helping with a Social Security claim, we must approve the fee.
We usually withhold 25 percent of past-due benefits in order to pay the approved (2) fee. We withheld $ (3) from (4) in case we need to pay (5) (6) .
We cannot tell you how much the (7) can charge at this time. When processing (8) claim we found we needed more information. To decide how much (9) benefits will be for (10) , we need (11) (12) (13) . When we get that information, we will decide the amount of (14) past-due benefits and send another letter telling you how much the (15) can charge. You can help us finish the work on (16) claim by taking the information to any Social Security office.
Fill-ins:
(1) “representative”
(2) “representative's”
(3) show the total fee amount withheld from all PICs/Show the single PICs fee amount
withheld
(4) “the benefits due you and your family”/“your benefits”
(5) always use “the”
(6) “representative”
(7) “representative”
(8) Ms. plus BLN (possessive)/ Mr. plus BLN (possessive)/“your”
(9) “her”/“his”/“your”
(10) Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY
(11) Manual fill-in 1 which can include choices A or B
A. proof of
B. more information about
(12) “her”/“his”/“your”
(13) Manual fill-in 2 which can include choices of workers' compensation benefits/public
disability benefits/workers' compensation and public disability benefits/military
service/date of birth/or free format reason*
(14) “her”/“his”/“your”
(15) “representative”
(16) “her”/“his”/“your”
(*) indicates that the fill-in is manual
ATY004 Fee Petition not Received/Approved and Direct Payment Not Waived
We generally must approve any fee (1) representative wants to charge for helping with (2) Social Security claim. The representative should send us a fee request when he or
she has finished all work on the claim. If the representative will not charge a fee,
he or she must tell us by sending a signed and dated statement.
Fill-ins:
(1) “your”/name, possessive
(2) “your”/“his”/“her”
ATYR05 Fee Agreement Amount - Auxiliary
(1) past-due benefits are (2) for (3) . Under the fee agreement between (4) and the (5) , the (6) cannot charge more than (7) for his or her work.
Fill-ins:
(1) FN possessive
(2) amount
(3) month and year/month and year through month and year
(4) person that signs the fee agreement*
(5) “lawyer”/“representative”
(6) “lawyer”/“representative”
(7) money amount *
(*) indicates that the fill-ins are manual
ATY005 Attorney Fees Withheld - Petition
When the amount of the fee is decided, we will pay the lawyer from the benefits we
withheld.
ATYO05 Attorney Fees Withheld - Petition
If the approved fee is more than the money we have withheld, the Social Security Administration
is not involved in paying the rest of the fee.
ATYR06 Notify a Beneficiary with Representative that Fee Authorization Cannot be Released
at Time of Effectuation. (WC/PDB Decision or Appeal of a Denied WC/PDB Claim is Pending)
When a representative wants to charge for helping with a Social Security claim, we
must approve the fee.
We cannot tell you how much the representative can charge at this time. When processing
(1) claim we found we needed more information. To decide how much (2) benefits will be for (3) , we need (4) (5) (6) . When we get that information, we will decide the amount of (7) past-due benefits and send another letter telling you how much the representative
can charge. You can help us finish the work on (8) claim by taking the information to any Social Security office.
Fill-ins:
(1) Ms. plus BLN (possessive)/Mr. plus BLN (possessive)/“your”
(2) “her”/“his”/“your”
(3) Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY
(4) Manual fill-in 1 which can include choices A or B
A. proof of
B. more information about
(5) “her”/“his”/“your”
(6) Manual fill-in 2 which can include choices of workers' compensation benefits/public
disability benefits/workers' compensation and public disability benefits/military
service/date of birth/or free format reason*
(7) “her”/“his”/“your”
(8) “her”/“his”/“your”
(*) indicates that the fill-in is manual
ATY007 Fee Withholding Information - Petition
If the approved fee is less than the money we have withheld, we will send (1) (2) .
Fill-ins:
(1) SN
(2) “the rest of the money”
ATY008 Attorney Appointment Questionable Award
We need more information to decide whether a lawyer represents (1) in (2) claim for Social Security benefits. We will contact you for this information.
Fill-ins:
(1) SN
(2) “your”/“her”/“his”
ATY009 Attorney Representation Questionable
We need more information to decide whether a lawyer represents (1) After we decide this, we will let you know if (2) (3) due any of the money we have withheld.
Fill-ins:
(1) Beneficiary's full name
(2) SN
(3) “is”/“are”
ATY010 Non-Attorney Representative, Fee Not Waived, Award
Your representative must receive approval from the Social Security Administration
before a fee can be charged. If the representative wants to charge a fee, a request
for approval must be sent to us as soon as all work for (1) is finished. If no fee will be charged, we should also be told right away.
ATY011 Address for Sending Fee Petition
Any request for fee approval should be sent to: (1)
Fill-in:
(1) Address to which petition is sent
ATY012 Attorney Waived Option to Direct Payment
However, the lawyer has asked us to send all past due benefits to (1) .
Fill-in:
(1) “you”/“her”/“him”
ATYR12 Explanation of Withholding - Auxiliary
Because of the law, we usually withhold 25 percent of the total past-due benefits
to pay an approved lawyer's fee. We withheld $ (1) from (2) past-due benefits to pay (3) lawyer.
Fill-ins:
(1) money amount
(2) “your”/name, possessive
(3) “the”
ATY013 Attorney has not Waived Fee, No Past Due Benefits
However, there are no past due benefits available to be paid to the lawyer.
ATY014 Attorney Waived Fee, Award
However, the lawyer has told us that no fee will be charged for services on this Social
Security claim. For this reason, no past due benefits have been withheld to pay the
lawyer.
ATYR15 Disapproval of Fee Agreement
We cannot approve the fee agreement between you and your representative because (1) (1). Even though we cannot approve the fee agreement, your representative can still
charge you a fee for his or her services. If your representative wants to charge a
fee, he or she must ask us in writing to approve the amount of the fee. Your representative
must give you a copy of his or her fee request and each attachment to the request.
If your representative does not want to charge a fee, he or she should tell us.
Fill-ins:
(1) Manual fill-in 1, choice of A through H:
(A) we did not get a written agreement before
we decided your claim.
(B) both you and your representative did
not sign the agreement.
(C) it sets a fee amount that is more than the lesser of 25 percent of
past-due benefits or
$7200.00.
(D) there are no past-due benefits. We base
the fee amount we allow under a fee agreement on your past-due benefits.
Since we do not owe you any past-due benefits, we cannot approve the
fee agreement.
(E) you appointed more than one representative,
and not all representatives signed onto a single fee agreement.
(F) you discharged a representative, or a
representative withdrew from the case, before we favorably decided
the claim (unless the former representative waived any fee in your
case).
(G) your representative died before we issued
the favorable decision.
(H) you were declared legally incompetent
by a State court and your guardian did not sign the fee agreement.*
ATY016 Explanation of Attorney Fee Assessment (With Cap)
We are paying the (1) from the benefits we withheld. Therefore, we must collect a service charge from him
or her. The service charge is 6.3 percent of the fee amount we pay, but not more than
$117, which is the most we can collect in each case under the law. We will subtract
the service charge from the amount payable to the (2) . (3)
The (4) cannot ask you to pay for the service charge. If the (5) disagrees with the amount of the service charge, he or she must write to the address
shown at the top of this letter. The (6) must tell us why he or she disagrees within 15 days from the day he or she gets this
letter.
Fill-ins:
(1) “representative”
(2) “representative”
(3) After we subtract the amount we are paying towards the fee, we will send you the
balance of the amount we withheld/NULL
(4) “representative”
(5) “representative”
(6) “representative”
ATY018 Non-Attorney Representative, Fee Waived, Award
Your representative told us that a fee will not be charged. If a fee is charged, your
representative must receive approval from the Social Security Administration.
ATYR20 Fee Amount – Number Holder Only – Delayed Auxiliary Claims Pending or Expected
We base the amount of the (1) fee on the total past-due benefits for you and your family. Your past-due benefits
are
$ (2) for (3) . Under the fee agreement, the (4) can charge you $ (5) for his or her work. As soon as we make a decision on your family's claim(s) and
decide the amount of their past-due benefits, we will tell them if the (6) can charge an additional fee. We also will say how much that fee amount will be.
The amount of the fee for your and your family's claim(s) does not include any out-of-pocket
expenses (for example, costs to get copies of doctors' or hospitals' reports). This
is a matter between you and the (7) .
Fill-ins:
(1) “lawyer's”/“representative's”
(2) Show amount of the N/H's past-due benefits in format “$$$$.¢¢”
(3) MM/YYYY or MM/YYYY through MM/YYYY
(4) “lawyer”/“representative”
(5) Show amount of the fee in $$$$.¢¢ format.
(6) “lawyer”/“representative”
(7) “lawyer”/“representative”
ATYR22 Fee Amount – Number Holder and Non-Delayed Auxiliary Beneficiary(ies) – Delayed Auxiliary
Claims Pending or Expected
We base the amount of the (1) fee on the total past-due benefits for you and your family. Your past-due benefits
are $ (2) for (3) . (4) past-due benefits are $ (5) for (6) . Under the fee agreement, the (7) can charge you and (8) $ (9) for his or her work. As soon as we make a decision on your (10) and decide the amount of the past-due benefits, we will tell (11) if the (12) can charge an additional fee. We also will say how much that fee amount will be.
The amount of the fee for your and your family's claim(s) does not include any out-of-pocket
expenses (for example, costs to get copies of doctors' or hospitals' reports). This
is a matter between you and the (13) .
Fill-ins:
(1)
Choice 1 - lawyer's
Choice 2 - representative's
(2) The amount of the N/H's past-due benefits in $$$$.¢¢ format.
(3)
Choice 1 - MM/YYYY
Choice 2 - MM/YYYY through MM/YYYY
(4)
Choice 1 - (current action involves only
one auxiliary beneficiary) - insert possessive case of name of auxiliary
beneficiary, in the format First Name, Last Name. Example: Henry James.
Choice 2 - (current action involves two or
more auxiliary beneficiaries) - insert possessive case of names of
auxiliary beneficiaries, in the format First Name, Last Name, (separated
by commas and/or “and,” as appropriate). Example: Henry
James, William Jones, and Alice James. *
(5) The amount of the non-delayed auxiliary beneficiary's (ies') past-due benefits
*
(6)
Choice 1 – MM/YYYY
Choice 2 - MM/YYYY through MM/YYYY
(7)
Choice 1 - lawyer
Choice 2 - representative
(8)
Choice 1 - (current action involves only
one auxiliary beneficiary) - insert name of auxiliary beneficiary,
in the format First Name, Last Name. Example: Henry James.
Choice 2 - (current action involves two or
more auxiliary beneficiaries) - insert names of auxiliary beneficiaries,
in the format First Name, Last Name, (separated by commas and/or “and,” as appropriate). Example: Henry James, William James,
and Alice James. *
(9) The amount of the fee based on total past-due benefits for the N/H's claim and
any non-delayed auxiliary claims *
(10)
Choice 1 - spouse's claim
Choice 2 - other child's claim
Choice 3 - other children's claims
Choice 4 - spouse's and other child's
claims
Choice 5 - spouse's and other children's
claims *
(11)
Choice 1 - him
Choice 2 - her
Choice 3 - them *
(12)
Choice 1 - lawyer
Choice 2 - representative
(13)
Choice 1 - lawyer
Choice 2 - representative
(*) indicates that the fill-ins are manual
ATY023 Auxiliary's Past-Due Benefit (s) Withheld – SSI Pending
We also withheld (1) from (2) family's past-due benefits.
Fill-ins:
(1) legal payment deduction amount
(2) “your”/“her”/“his”
ATY079 Claim is Denied and No Fee Agreement Type is Present
(1) (2) must ask us for approval before charging a fee. If (3) (4) wants to charge a fee, a request for approval must be sent to us as soon as all work
on this case for (5) (6) is finished.
Fill-ins:
(1) SN possessive
(2) “lawyer”/“representative”
(3) SN possessive
(4) “lawyer”/“representative”
(5) SN
(6) null
ATY080 Attorney/Non-Attorney Representation Questionable, Disallowance
An attorney or other representative must ask us for approval before charging a fee.
If (1) a representative who wants to charge a fee, a request for approval must be sent to
us as soon as all work on this case is finished. If no fee will be charged, we should
also be told right away. If the fee is approved, the Social Security Administration
will not be involved in paying the fee.
Fill-in:
(1) “you have”/“she has”/“he
has”
ATY081 Non-Attorney/Attorney Fee Waived, Disallowance
(1) has told us that a fee will not be charged for helping (2) (3) with (4) claim.
Fill-ins:
(1) attorney name/representative name
(2) SN
(3)
“and [3a] family members”/null
[3a] “your”/“her”/“his”
(4)
ATY800 Fee Agreement Approval – Number Holder
We have approved the fee agreement between you and your (1) .
Fill-in:
(1) “lawyer”/“representative”
ATY801 Fee Agreement Approval - Auxiliary
When (1) filed (2) claim for benefits, (3) used a (4) to help with the claim. We have approved a fee agreement between (5) and (6) (7) . The (8) work involved the benefits of everyone on the record.
Fill-ins:
(1) beneficiary name
(2) “your”/“her”/“his”
(3) “you”/“she”/“he”
(4) “lawyer”/“representative”
(5) beneficiary name
(6) “the”
(7) “lawyer”/“representative”
(8) “lawyer's”/“representative's”
ATY804 Fee Agreement Amount – Number Holder
(1) past-due benefits are (2) for (3) . Under the fee agreement, the (4) cannot charge you more than (5) for his or her work. The amount of the fee does not include any out-of-pocket expenses
(for example, costs to get copies of doctors or hospitals reports). This is a matter
between you and your (6) .
Fill-ins:
(1) “Your”/FN possessive
(2) money amount
(3) month and year/month and year through month and year
(4) “lawyer”/“representative”
(5) pending fee amount
(6) “lawyer”/“representative”
ATY808 Procedure for Review of Fee Under Fee Agreement – Number Holder
You, your representative, or the person who decided your case can ask us to review
the amount of the fee we say your representative can charge. (1)
If you think the amount of the fee is too high, write us within 15 days from the day
you get this letter. Tell us that you disagree with the amount of the fee and give
your reasons. Send your request to this address:
(2)
(3)
(4)
(5)
(6)
(7)
Your representative also has 15 days to write us if he or she thinks the amount of
the fee is too low.
If we do not hear from you or your representative , we will assume you both agree
with the amount of the fee shown.
Fill-ins:
(1) /“Your
family members who have filed claims on your Social Security number (SSN) also may
ask us to review
the amount of the fee.”/null
(2) Show the Administrative Law Judge name (first and last name)
(3) Show Line 1 of Mailing Address in DOORS
(4) Show Line 2 of Mailing Address in DOORS
(5) Show Line 3 of Mailing Address in DOORS
(6) Show Line 4 of Mailing Address in DOORS
(7) Show Line 5 of Mailing Address in DOORS
ATY809 Procedure for Review of Fee Under Fee Agreement - Auxiliary
You, your representative, or the person who decided your case can ask us to review
the amount of the fee we say your representative can charge.
If you think the amount of the fee is too high, write us within 15 days from the day
you get this letter. Tell us that you disagree with the amount of the fee and give
your reasons. Send your request to this address:
(1)
(2)
(3)
(4)
(5)
(6)
Your representative also has 15 days to write us if he or she thinks the amount of
the fee is too low.
If we do not hear from you or your representative , we will assume you both agree
with the amount of the fee shown.
Fill-ins:
(1) Show Administrative Law Judge name (first and last name)
(2) Show Line 1 of Mailing Address in DOORS
(3) Show Line 2 of Mailing Address in DOORS
(4) Show Line 3 of Mailing Address in DOORS
(5) Show Line 4 of Mailing Address in DOORS
(6) Show Line 5 of Mailing Address in DOORS
ATY816 Attorney Responsibilities – Fee Agreement Disapproved
If your lawyer wants us to pay the fee from your withheld benefits, he or she must
ask us to approve the fee within 60 days of the date of this letter.
If your lawyer:
-
Is finished working on this case and wants to charge a fee, he or she should ask us
to approve the amount of the fee right away.
-
Is not finished working on this case and wants to charge a fee, he or she must tell
us within 60 days of the date of this letter that he or she will ask for a fee.
-
Does not want to charge a fee or does not want us to pay the fee from the benefits
we withheld, he or she should tell us right away.
ATY817 Review of Determination on Fee Agreement
You or your representative can ask us to review the determination on the fee agreement.
If you decide to ask us for a review, write us within 15 days from the day you get
this letter. Tell us that you disagree and give your reasons. Send your request to
this address:
(1)
(2)
(3)
(4)
(5)
(6)
Your representative also has 15 days to write us if he or she does not agree with
the determination on the fee agreement.
Fill-ins:
(1) Show the Administrative Law Judge name (first and last name)
(2) Show Line 1 of Mailing Address in DOORS
(3) Show Line 2 of Mailing Address in DOORS
(4) Show Line 3 of Mailing Address in DOORS
(5) Show Line 4 of Mailing Address in DOORS
(6) Show Line 5 of Mailing Address in DOORS
ATY825 Fee Agreement Amount – Concurrent Title II/Title XVI – Additional Fee for Title XVI
Claim – Number Holders Only
If we approve your claim for SSI, the (1) may be able to charge an additional amount for his or her work. We will send you
another letter about SSI telling you the additional amount of the fee, if any, he
or she can charge.
Fill-ins:
(1) “lawyer”/“representative”
ATY834 Fee Agreement Amount – Number Holder and Family
(1) past-due benefits are (2) for (3) . (4) family's past-due benefits are (5) for (6) . Under the fee agreement, the (7) cannot charge (8) and (9) family more than (10) for his or her work. The amount of the fee does not include any out-of-pocket expenses
(for example, costs to get copies of doctors' or hospitals' reports). This is a matter
between you and the (11) .
Fill-ins:
(1) “Your”/FN possessive
(2) money amount
(3) month and year/month and year through month and year
(4) “your”/“her”/“his”
(5) money amount
(6) month and year/month and year through month and year
(7) “lawyer”/“representative”
(8) “you”/SN
(9) “your”/“her”/“his”
(10) the total fee amount
(11) “lawyer”/“representative”
ATY836 Explanation to the Beneficiary About the Withholding of Representative Fees from Past-Due
Benefits
Based on the law, we must withhold part of past-due benefits to pay an appointed representative.
We cannot withhold more than 25 percent of past-due benefits to pay an authorized
fee. We withheld (1) from (2) past-due benefits to pay (3) representative.
Fill-ins:
(1) money amount
(2) “Mr.” plus BLN possessive/“Ms.” plus BLN possessive/null plus BGN possessive/null plus FN possessive/“your”
(3) “the”
ATY838 Explanation of Withholding – Fee Agreement – Amount Withheld Greater than Fee Amount
– SSI Pending – Number Holder's Family
Because of the law, we usually withhold 25 percent of the total past-due benefits
to pay an approved lawyer's fee. We withheld (1) from (2) past-due benefits to pay (3) lawyer. We also withheld (4) from (5) family's past-due benefits. We base the amount of the fee (6) lawyer can charge on the total past-due benefits due (7) and (8) family.
Fill-ins:
(1) money amount
(2) “your”/name, possessive
(3) “the”
(4) money amount
(5) “your”/“her”/“his”
(6) “the”
(7) “you”/name
(8) “your”/“her”/“his”