TN 3 (03-95)
GN 03960.090 Exhibit - Decision Maker Request for Administrative Review and Transmittal
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MEMORANDUM TO
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: NE MAT SE GL WN MAM ODIO Processing Center
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. - - ,
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Account # & Symbol
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Name of Wage Earner or Beneficary
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| FROM |
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SUBJECT
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Request for Administrative Review of Fee Based on an Approved Fee Agreement — ACTION
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I approved the fee agreement between
(Name of Claimant)
and .
(Name of Representative)
I ask for a reduction of the fee which would otherwise result under the agreement
because, I believe, the evidence shows:
(Designate One)
/ / the fee is clearly excessive in light of the services provided
/ / did not represent the claimant's interest adequately.
Name of Representative
My reasons follow.
Attachment(s) / / Yes / /No
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, Claimaint |
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, Representative |
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, Auxiliary Beneficary(ies) |
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