Use the following language to inform the claimant and the representative when we fail
to withhold past due benefits for title XVI claims. Send the notice to the claimant
and a copy to the representative.
“We show that you chose (1) to act as your representative in your claim for Supplemental Security Income. By
law, we must hold back up to 25 percent of your past-due benefits to pay the representative.
We should have held $(3) from your benefits to pay all or part of the fee. Since we released these benefits
to you, the representative will look to you for payment of your share of the fee.
Your share of the authorized fee is $(4).
The representative may contact us at the above address if you do not pay the fee.
If the representative asks us to collect payment from you, we will:
pay the representative the amount we should have held from you, minus any service
charge we must keep by law; and
recover from you the amount we should have held.
If the authorized fee is more than the amount we should have held, you must pay any
remaining fee balance.
We will send your representative a copy of this notice.”
(1) Representative’s name
(2) Choice 1 – However, we paid all past-due benefits to you.
Choice 2 – After we reimbursed the State, we paid all remaining past-due benefits
(3) Amount we should have withheld from the claimant’s past-due benefits for payment
of the representative’s fee as determined in GN 03920.017D Procedure – Amount of Direct Payment prior to imposing the assessment on the representative’s
(4) Authorized fee owed by this claimant
NOTE: All fee notices that involve the spouse in a title XVI couples case are manual notices.
Adjust the notice in GN 03920.055B.2. in this section, as necessary, when notifying the spouse.