TN 8 (02-05)
GN 03930.170 Model Fee Notice – Direct Fee Payment to Representative from Title XVI Withheld Past-Due Benefits
We are writing to tell you more about the fee we authorized your representative to charge for his or her services on your Supplemental Security Income (SSI) claim
Information About Past-Due Benefits Withheld to Pay Your Representative
Your representative is eligible to receive direct payment of the fee we approve. We withheld money from your past-due benefits to pay the representative.
The fee that the representative is approved to charge is $1,600.
We are paying the representative from the benefits we withheld.
Because we are paying the fee from your benefits, we must collect a service charge from the representative. The service charge is 6.3 percent of the fee amount we pay, but not more than $77.00, 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 representative. This means that we subtract $77 from the $1,500 we are paying toward the representative’s fee, and send him or her $1,423.
The representative cannot ask you to pay for the service charge. If the representative disagrees with the amount of the service charge, he or she must write to our address shown above. The representative must tell us why he or she disagrees within 15 days from the day he or she gets this letter.
The fee we approved is more than the money we withheld and paid to your representative. Payment of the remainder of the approved fee, $100, is a matter between you and your representative.
NOTE: The assessment paragraph at the fourth bullet will vary depending on the circumstances in the claim. Refer to GN 03920.019K., Procedure – Notice Language.)