TN 19 (07-05)

GN 03940.085 Title XVI Fee Agreement Paragraphs

A. Overview

The captions and paragraphs in this section are for use in title XVI fee notices. GN 03940.085B. - GN 03940.085K. include:

  • captions and paragraphs [Universal Text Identifiers (UTIs)] used in systems generated notices, and

  • additional UTIs that are only available in the Document Processing System (DPS) for inclusion in manual notices.

See GN 03940.055B. for the fee situations that require a manual notice.

NOTE: The variables in the automated notice paragraph and the corresponding manual notice paragraph may differ for some UTIs. If there is a question about coding a specific UTI, refer to the Language Development Facility on Policy Net through the link under Useful Tools, or at http://policynet.ba.ssa.gov/ldfsearch.nsf .

B. Exhibit - Fee Agreement In File - Favorable Determination Or Decision On Title XVI Claim

1. Description - UTI XVI720 (DPS UTI ATY019 or use DPS FEE038) - Lead-In Paragraph

We are writing to tell you about the fee agreement with (1) (2).

Fill-Ins:

  1. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z) 
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  2. Choice 1: lawyer
    Choice 2: representative

2. Description - DPS UTI FEE038 - Lead-In Paragraph

We are writing to tell you about the fee agreement with your (1). This information is also being sent to (2).

Fill-Ins:

  1. Choice 1: lawyer
    Choice 2: representative

  2. TEXT FILL

C. Exhibit - Fee Agreement Approved

1. Description - Caption XVI357 (DPS Caption ATYC06)

We Have Approved the Fee Agreement

2. Description - UTI XVI527 (DPS UTI ATY020) - Field Office Approves Fee Agreement - Title XVI Only

We have approved the fee agreement between (1) and (2) (3).

Fill-in:

  1. Choice 1: you
    Choice 2: Claimant’s name

  2. Choice 1: your
    Choice 2: her
    Choice 3: his

  3. Choice 1: lawyer
    Choice 2: representative

D. Exhibit - Fee Agreement Disapproved - Title XVI Only

1. Description - Caption XVI358 (DPS Caption ATYC08 for choice 1 or Caption FEEC10 for choice 2)

We (1) Approve The Fee Agreement

Fill-Ins:

  1. Choice 1: Do Not
    Choice 2: No longer

2. Description - UTI XVI535 (DPS UTI FEE060) - Field Office Disapproves Fee Agreement - Title XVI Only

We cannot approve the fee agreement between (1) and (2) (3) because (4).

Fill-Ins:

  1. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  2. Choice 1: your
    Choice 2: her
    Choice 3: his

  3. Choice 1: lawyer
    Choice 2: representative

  4. Choice 1: we did not get a written agreement before we decided your claim
    Choice 2: we did not get a written agreement before we decided her claim
    Choice 3: we did not get a written agreement before we decided his claim
    Choice 4: both you and your lawyer did not sign the agreement
    Choice 5: both she and her lawyer did not sign the agreement
    Choice 6: both he and his lawyer did not sign the agreement
    Choice 7: both you and your representative did not sign the agreement
    Choice 8: both she and her representative did not sign the agreement
    Choice 9: both he and his representative did not sign the agreement
    Choice 10:  (Obsolete)
    Choice 11: there are no past-due benefits. We base the fee amount we allow under a fee agreement on your past-due benefits. Since there are no past-due benefits, we cannot approve the fee agreement
    Choice 12: there are no past-due benefits. We base the fee amount we allow under a fee agreement on her past-due benefits. Since there are no past-due benefits, we cannot approve the fee agreement
    Choice 13: there are no past-due benefits. We base the fee amount we allow under a fee agreement on his past-due benefits. Since there are no past-due benefits, we cannot approve the fee agreement
    Choice 14: it sets a fee amount that is more than 25 percent of past-due benefits or $6,000

3. Description - UTI XVI532 (DPS UTI FEE061) - Fee Agreement Previously Approved - Now Disapprove - No Past-Due Benefits

We wrote you before and said we had approved the fee agreement between (1) and (2) (3). We also said we would tell you and (4) (5) the amount of the fee (6) (7) can charge (8).

We base the fee amount we allow under a fee agreement on (9) past-due benefits. There are no past-due benefits. Therefore, we no longer approve the fee agreement between (10) and (11) (12).

Fill-Ins:

  1. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  2. Choice 1: your
    Choice 2: her
    Choice 3: his

  3. Choice 1: lawyer
    Choice 2: representative

  4. Choice 1: your
    Choice 2: her
    Choice 3: his

  5. Choice 1: lawyer
    Choice 2: representative

  6. Choice 1: your
    Choice 2: her
    Choice 3: his

  7. Choice 1: lawyer
    Choice 2: representative

  8. Choice 1: you
    Choice 2: her
    Choice 3: him

  9. Choice 1: your
    Choice 2: her
    Choice 3: his

  10. Choice 1: you
    Choice 2: her
    Choice 3: him

  11. Choice 1: your
    Choice 2: her
    Choice 3: his

  12. Choice 1: lawyer
    Choice 2: representative

4. Description - DPS UTI FEE058 - Administrative Law Judge or Administrative Appeals Judge Disapproved Fee Agreement - Advise About Withholding Past-Due Benefits

We wrote you before and said we had disapproved the fee agreement between (1) and (2) (3).

Fill-Ins

  1. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  2. Choice 1: your
    Choice 2: her
    Choice 3: his

  3. Choice 1: lawyer
    Choice 2: representative

5. Description - UTI XVI534 (DPS UTI ATY050) - File Fee Petition - Representative Not Eligible for Direct Fee Payment

Even though we (1) approve the fee agreement, (2) (3) can still charge (4) a fee for his or her services. If (5) (6) wants to charge a fee, he or she must ask us in writing to approve the fee. (7) (8) must give (9) a copy of his or her fee request and each attachment to the request. If (10) (11) does not want to charge a fee, he or she should tell us.

Fill-Ins:

  1. Choice 1: no longer
    Choice 2: cannot

  2. Choice 1: your
    Choice 2: her
    Choice 3: his

  3. Choice l: lawyer
    Choice 2: representative

  4. Choice 1: you
    Choice 2: her
    Choice 3: him

  5. Choice 1: your
    Choice 2: her
    Choice 3: his

  6. Choice l: lawyer
    Choice 2: representative

  7. Choice 1: Your
    Choice 2: Her
    Choice 3: his

  8. Choice 1: lawyer
    Choice 2: representative

  9. Choice 1: you
    Choice 2: her
    Choice 3: him

  10. Choice 1: your
    Choice 2: her
    Choice 3: his

  11. Choice 1: lawyer
    Choice 2: representative

6. Description - DPS UTI ATY045 - File Fee Petition - Representative Eligible for Direct Fee Payment

Even though we (1) approve the fee agreement, (2) (3) can still charge (4) a fee for his or her services. If (5) (6) wants to charge a fee, he or she must ask us in writing to approve the fee. The (7) must give you a copy of his or her fee request and each attachment to the request.

Fill-Ins:

  1. Choice 1: no longer
    Choice 2: cannot

  2. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  3. Choice 1: lawyer
    Choice 2: representative

  4. Choice 1: you
    Choice 2: her
    Choice 3: him

  5. Choice 1: your
    Choice 2: her
    Choice 3: his

  6. Choice 1: lawyer
    Choice 2: representative

  7. Choice 1: lawyer
    Choice 2: representative

E. Exhibit - Information About The Fee

1. Description - Caption XVI717 (DPS Caption ATYC10)

Information About (1) (2) Fee

Fill-Ins:

  1. Choice 1: Your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  2. Choice 1: Lawyer’s
    Choice 2: Representative’s

2. Description - UTI FEE003 (DPS UTI FEE003) - Agreement Previously Approved - Now Tell Authorized Fee

We told you in another letter that we had approved the fee agreement between (1) and (2). Now we can tell you and (3) about the amount of the fee (4) can charge (5).

Fill-Ins:

  1. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  2. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

  3. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

  4. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

  5. Choice 1: you
    Choice 2: her
    Choice 3: him

3. Description - DPS UTI FEE051 - SSA Previously Notified Recipient of ODAR Fee Agreement Approval - Spouse’s Benefits Used to Calculate Fee

We told (1) in another letter that we had approved the fee agreement between (2) and (3) (4). Now we can tell (5) and (6) (7) about the amount of the fee (8) (9) can charge (10) under the agreement.

(11) (12) can charge (13) no more than $(14) for his or her work under the agreement. The fee does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). (15) past-due benefits used to decide the amount of the fee are $(16) for (17). In addition, because (18) (19)’s work resulted in (20), we used (21) spouse’s SSI past-due benefits for (22), $(23), to decide the amount of the fee.

Fill-ins:

  1. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  2. Choice 1: you
    Choice 2: her
    Choice 3: him

  3. Choice 1: your
    Choice 2: her
    Choice 3: his

  4. Choice 1: lawyer
    Choice 2: representative

  5. Choice 1: you
    Choice 2: her
    Choice 3: him

  6. Choice 1: your
    Choice 2: her
    Choice 3: his

  7. Choice 1: lawyer
    Choice 2: representative

  8. Choice 1: your
    Choice 2: her
    Choice 3: his

  9. Choice 1: lawyer
    Choice 2: representative

  10. Choice 1: you
    Choice 2: her
    Choice 3: him

  11. Choice 1: Your
    Choice 2: Her
    Choice 3: His

  12. Choice 1: lawyer
    Choice 2: representative

  13. Choice 1: you
    Choice 2: her
    Choice 3: him

  14. MONEY FILL (Approved fee based on recipient’s and spouse’s past-due benefits)

  15. Choice 1: Your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  16. MONEY FILL (Recipient’s past-due benefits)

  17. Choice l: DATE FILL (Month/Year)
    Choice 2: DATE FILL (Month/Year) through DATE FILL (Month/Year)

  18. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  19. Choice 1: lawyer
    Choice 2: representative

  20. Choice 1: an increase in your spouse’s SSI
    Choice 2: an increase in her spouse’s SSI
    Choice 3: an increase in his spouse’s SSI
    Choice 4: your spouse becoming eligible for SSI
    Choice 5: her spouse becoming eligible for SSI
    Choice 6: his spouse becoming eligible for SSI

  21. Choice 1: your
    Choice 2: her
    Choice 3: his

  22. Choice 1: DATE FILL (Month/Year)
    Choice 2: DATE FILL (Month/Year) through DATE FILL (Month/Year)

  23. MONEY FILL (Spouse’s past-due benefits)

4. Description - UTI XVI723 (DPS UTI ATY029) - Fee Amount Subsequently Known - Concurrent Titles II and XVI Claims - Title II Fee Amount Does Not Affect the Title XVI Fee Amount

We wrote you before and said we approved the fee agreement between (1) and (2) (3). We also said we would tell you and (4) (5) the amount of the fee he or she can charge (6) under the fee agreement. Since we have completed all our actions on (7) Social Security claim, we can now tell you the amount of the fee (8) (9) can charge (10).

Fill-Ins:

  1. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  2. Choice 1: your
    Choice 2: her
    Choice 3: his

  3. Choice 1: lawyer
    Choice 2: representative

  4. Choice 1: your
    Choice 2: her
    Choice 3: his

  5. Choice 1: lawyer
    Choice 2: representative

  6. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  7. Choice 1: your
    Choice 2: her
    Choice 3: his

  8. Choice 1: your
    Choice 2: her
    Choice 3: his

  9. Choice 1: lawyer
    Choice 2: representative

  10. Choice 1: you
    Choice 2: her
    Choice 3: him

5. Description - UTI FEE008 (DPS UTI FEE008) - Fee Authorized and Past-Due Benefits Amount Given

Under the fee agreement, (1) (2) can charge (3) no more than (4) for his or her work on (5) Supplemental Security Income (SSI) claim. The fee does not include any out-of-pocket expenses (for example, costs to get copies of doctors’ or hospitals’ reports). (6) SSI past-due benefits used to decide the amount of the fee are (7) for (8).

Fill-Ins:

  1. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  2. Choice 1: lawyer
    Choice 2: representative

  3. Choice 1: you
    Choice 2: her
    Choice 3: him

  4. MONEY FILL (Authorized fee)

  5. Choice 1: your
    Choice 2: TEXT FILL’s (Recipient’s name)
    Choice 3: TEXT FILL’ (Recipient’s name)

  6. Choice 1: Your
    Choice 2: Her
    Choice 3: His

  7. MONEY FILL (Amount of past-due benefits)

  8. Choice 1: DATE FILL (Month/Year)
    Choice 2: DATE FILL (Month/Year) through DATE FILL (Month/Year)

6. Description - UTI XVI726 (DPS UTI ATY027) - Concurrent Title II and XVI - Explanation of Title XVI Portion of Fee

In deciding the amount of the fee (1) (2) can charge for (3) SSI claim, we also considered that:

  • we already approved a fee for (4) for (5) Social Security claim, and

  • (6) (7) cannot charge more than a total of (8) under the fee agreement for (9) Social Security and SSI claims.

Fill-Ins:

  1. Choice 1: your
    Choice 2: her
    Choice 3: his

  2. Choice 1: lawyer
    Choice 2: representative

  3. Choice 1: your
    Choice 2: her
    Choice 3: his

  4. MONEY FILL (Fee authorized under title II)

  5. Choice 1: your
    Choice 2: her
    Choice 3: his

  6. Choice 1: your
    Choice 2: her
    Choice 3: his

  7. Choice 1: your
    Choice 2: representative

  8. MONEY FILL (Combined title II and title XVI authorized fee)

  9. Choice 1: your
    Choice 2: her
    Choice 3: his

7. Description - DPS UTI FEE089 - Title XVI Only - Spouse’s Benefits Used to Calculate Fee

Under the fee agreement, (1) (2) can charge (3) no more than $(4) for his or her work on (5) Supplemental Security Income (SSI) claim. The fee does not include any out-of-pocket expenses (for example, costs to get copies of doctors’ or hospitals’ reports). (6) SSI past-due benefits used to decide the amount of the fee are $(7) for (8). In addition, because (9) (10)’s work resulted in (11), we used (12) spouse’s SSI past-due benefits for (13), $(14), to decide the amount of the fee.

Fill-Ins:

  1. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  2. Choice 1: lawyer
    Choice 2: representative

  3. Choice 1: you
    Choice 2: her
    Choice 3: him

  4. MONEY FILL (Fee based on recipient’s and spouse’s past-due benefits)

  5. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  6. Choice 1: Your
    Choice 2: Her
    Choice 3: His

  7. MONEY FILL (Recipient’s past-due benefits)

  8. Choice 1: DATE FILL (Month/Year)
    Choice 2: DATE FILL (Month/Year) through DATE FILL (Month/Year)

  9. Choice 1: your
    Choice 2: TEXT FILE’s (Enter the recipient’s name if the notice is for the representative payee and recipient’s name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  10. Choice 1: lawyer
    Choice 2: representative

  11. Choice 1: an increase in your spouse’s SSI
    Choice 2:  an increase in her spouse’s SSI
    Choice 3: an increase in his spouse’s SSI
    Choice 4: your spouse becoming eligible for SSI
    Choice 5: her spouse becoming eligible for SSI
    Choice 6: his spouse becoming eligible for SSI

  12. Choice 1: your
    Choice 2: her
    Choice 3: his

  13. Choice 1: DATE FILL (Month/Year)
    Choice 2: DATE FILL (Month/Year) through DATE FILL (Month/Year)

  14. MONEY FILL (Spouse’s past-due benefits)

8. Description - DPS UTI FEE092 - Concurrent Titles II and XVI - Spouse’s Benefits Used to Calculate Fee

Under the fee agreement, (1) (2) can charge (3) no more than $(4) for his or her work. The fee does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). (5) past-due benefits used to decide the amount of the fee are $(6) for (7). In addition, because (8) (9)’s work resulted in (10), we used (11) spouse’s SSI past-due benefits for (12), $(13), to decide the amount of the fee.

Fill-Ins:

  1. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  2. Choice 1: lawyer
    Choice 2: representative

  3. Choice 1: you
    Choice 2: her
    Choice 3: him

  4. MONEY FILL (Amount of Fee - Rounded up to the next whole cent, based on recipient’s and spouse’s past-due benefits)

  5. Choice 1: Your
    Choice 2: Her
    Choice 3: His

  6. MONEY FILL (Amount of recipient’s past-due benefits)

  7. Choice l: DATE FILL (Month/Year)
    Choice 2: DATE FILL (Month/Year) through DATE FILL (Month/Year)

  8. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3:  TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  9. Choice 1: lawyer
    Choice 2: representative

  10. Choice 1: an increase in your spouse’s SSI
    Choice 2: an increase in her spouse’s SSI
    Choice 3: an increase in his spouse’s SSI
    Choice 4: your spouse becoming eligible for SSI
    Choice 5: her spouse becoming eligible for SSI
    Choice 6: his spouse becoming eligible for SSI

  11. Choice 1: your
    Choice 2: her
    Choice 3: his

  12. Choice 1: DATE FILL (Month/Year)
    Choice 2: DATE FILL (Month/Year) through DATE FILL (Month/Year)

  13. MONEY FILL (Spouse’s past-due benefit)

9. Description - DPS UTI FEE094 - Title XVI Only - Delayed Spouse’s Claim Pending

We base the amount of the (1)’s fee on the total past-due benefits for (2) and (3) spouse. We include (4) spouse’s past-due benefits because the (5)’s work resulted in (6). (7) past-due benefits are $(8) for (9). Under the fee agreement, the (10) can charge (11) $(12) for his or her work. As soon as we finish processing (13) spouse’s claim and decide the amount of (14) past-due benefits, we will tell (15) if the (16) can charge an additional fee. We also will say how much that fee amount will be.

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 (17) and the (18).

Fill-Ins:

  1. Choice 1: lawyer
    Choice 2: representative

  2. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  3. Choice 1: your
    Choice 2: her
    Choice 3: his

  4. Choice 1: your
    Choice 2: her
    Choice 3: his

  5. Choice 1: lawyer
    Choice 2: representative

  6. Choice 1: an increase in your spouse’s SSI
    Choice 2: an increase in her spouse’s SSI
    Choice 3: an increase in his spouse’s SSI
    Choice 4: your spouse becoming eligible for SSI
    Choice 5: her spouse becoming eligible for SSI
    Choice 6: his spouse becoming eligible for SSI

  7. Choice 1: Your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  8. MONEY FILL (Recipient’s past-due benefits)

  9. Choice l: DATE FILL (Month/Year)
    Choice 2: DATE FILL (Month/Year) through DATE FILL (Month/Year)

  10. Choice 1: lawyer
    Choice 2: representative

  11. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  12. MONEY FILL (Pending fee agreement amount)

  13. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  14. Choice 1: her
    Choice 2: his

  15. Choice 1: you
    Choice 2: them

  16. Choice 1: lawyer
    Choice 2: representative

  17. Choice 1: you
    Choice 2: them

  18. Choice 1: lawyer
    Choice 2: representative

10. Description - DPS UTI FEE095 - Title XVI Only - Spouse’s Benefits Used to Calculate Fee - Notice to Spouse

When (1) spouse filed (2) claim for SSI, (3) used a (4) to help with the claim. We have approved a fee agreement between (5) and the (6). Under the fee agreement, (7) spouse’s representative can charge (8) no more than $(9) for his or her work. Because the (10)’s work resulted in (11) SSI benefits, we used (12) past-due benefits for (13), $(14), to decide the amount of the fee.

The (15) is eligible to receive direct payment of the fee we approve. Because of the law, we usually withhold part of the past-due benefits to pay an approved (16)’s fee. We withheld money from (17) past-due benefits to pay a portion of the fee.

Fill-Ins:

  1. Choice 1: your
    Choice 2: TEXT FILL’s (If notice is for spouse’s representative payee, and spouse’s name ends with other than -s, -x, or -z, enter spouse’s name)
    Choice 3: TEXT FILL’ (If notice is for spouse’s representative payee and spouse’s name ends in -s, -x, or -z, enter spouse’s name)

  2. Choice 1: her
    Choice 2: his

  3. Choice 1: she
    Choice 2: he

  4. Choice 1: lawyer
    Choice 2: representative

  5. Choice 1: her
    Choice 2: him

  6. Choice 1: lawyer
    Choice 2: representative

  7. Choice 1: your
    Choice 2: TEXT FILL’s (Enter spouse’s name if name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter spouse’s name if name ends with -s, -x, or -z)’

  8. Choice 1: you and your spouse
    Choice 2: her and her spouse
    Choice 3: him and his spouse

  9. MONEY FILL (Amount of Fee - Rounded up to the next whole cent)

  10. Choice 1: lawyer
    Choice 2: representative

  11. Choice 1: an increase in your
    Choice 2: an increase in her
    Choice 3: an increase in his
    Choice 4: your becoming eligible for
    Choice 5: her becoming eligible for
    Choice 6: him becoming eligible for

  12. Choice 1: your
    Choice 2: her
    Choice 3: his

  13. Choice l: DATE FILL (Month/Year)
    Choice 2: DATE FILL (Month/Year) through DATE FILL (Month/Year)

  14. MONEY FILL (Spouse’s past-due benefits)

  15. Choice 1: lawyer
    Choice 2: representative

  16. Choice 1: lawyer
    Choice 2: representative

  17. Choice 1: your
    Choice 2: her
    Choice 3: is

11. Description - UTI XVI536 (DPS UTI FEE123) - Authorized Fee Revised

We told you in another letter how much (1) (2) could charge (3), under the fee agreement, for his or her work on (4) claim for Supplemental Security Income. That determination was not right. We are writing now to tell you the correct amount that (5) (6) can charge.

Fill-Ins:

  1. Choice 1: your
    Choice 2: her
    Choice 3: his

  2. Choice 1: lawyer
    Choice 2: representative

  3. Choice 1: you
    Choice 2: her
    Choice 3: him

  4. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  5. Choice 1: your
    Choice 2: her
    Choice 3: his

  6. Choice 1: lawyer
    Choice 2: representative

12. Description - UTI XVI724 (DPS UTI ATY030 - #13 choice 1, UTI ATY032 - #13 choice 2) - All Fee Amounts Known - Concurrent Titles II and XVI Claims - No Fee Amount Can Be Authorized on Title XVI Claim

We wrote you earlier about (1) fee agreement. We told you that (2) is the most (3) (4) can charge (5) under the fee agreement for his or her work on (6) Social Security claim. We are writing now to tell you that (7) is the (8) (9) (10) can charge (11) for his or her work on both (12) Social Security and Supplemental Security Income (SSI) claims. (13)

Fill-Ins:

  1. Choice 1: your
    Choice 2: her
    Choice 3: his

  2. MONEY FILL (Title II authorized fee)

  3. Choice 1: your
    Choice 2: her
    Choice 3: his

  4. Choice 1: lawyer
    Choice 2: representative

  5. Choice 1: you
    Choice 2: her
    Choice 3: him

  6. Choice 1: your
    Choice 2: her
    Choice 3: his

  7. MONEY FILL (Title II authorized fee)

  8. Choice 1: most
    Choice 2: only fee

  9. Choice 1: your
    Choice 2: her
    Choice 3: his

  10. Choice 1: lawyer
    Choice 2: representative

  11. Choice 1: you
    Choice 2: her
    Choice 3: him

  12. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  13. Choice 1: This means we cannot approve a higher fee based on SSI past-due benefits.
    Choice 2: This is because there are no SSI past-due benefits that we can use to decide the amount of the fee.

13. Description - UTI FEE022 (DPS UTI FEE022) - Non-Attorney Not Eligible for Direct Fee Payment

The Social Security Administration is not involved in paying the fee. This is a matter between (1) and (2).

Fill-Ins:

  1. Choice 1: you
    Choice 2: her
    Choice 3: him

  2. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

14. Description - UTI FEE033 (DPS UTI FEE033) - Representative Eligible for Direct Payment Waived Direct Payment

(1) is eligible to receive direct payment of the fee we approve. Because of the law, we usually withhold part of the past-due benefits to pay an approved (2) fee. However, (3) has asked us to send all past-due benefits to (4). Therefore, the Social Security Administration is not involved in paying the fee. This is a matter between (5) and (6).

Fill-Ins:

  1. Choice 1: Your lawyer
    Choice 2: Her lawyer
    Choice 3: His lawyer
    Choice 4: Your representative
    Choice 5: Her representative
    Choice 6: His representative

  2. Choice 1: lawyer’s
    Choice 2: representative’s

  3. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

  4. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  5. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  6. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

F. Exhibit - Information About the Fee Agreement - Concurrent Cases

1. Description - Caption XVI719 - Title II Fee Not Known

Information About The Fee Agreement With (1) (2) (Use DPS ATYC10)

Fill-Ins:

  1. Choice 1: Your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  2. Choice 1: Lawyer
    Choice 2: Representative

2. Description - UTI XVI721 (DPS UTI FEE062) - Fee Amount Unknown - Fee Agreement Approved By Field Office Title II Decision Maker

Once we complete all our actions on (1) Social Security claim, we will decide the amount of the fee, if any, (2) (3) can charge (4) for the work on (5) Supplemental Security Income (SSI) claim. We will send you another letter about SSI telling you the amount of the fee, if any, (6) (7) can charge (8) for the work on (9) SSI claim.

Fill-Ins:

  1. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  2. Choice 1: your
    Choice 2: her
    Choice 3: his

  3. Choice 1: lawyer
    Choice 2: representative

  4. Choice 1: you
    Choice 2: her
    Choice 3: him

  5. Choice 1: your
    Choice 2: her
    Choice 3: his

  6. Choice 1: your
    Choice 2: her
    Choice 3: his

  7. Choice 1: lawyer
    Choice 2: representative

  8. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  9. Choice 1: your
    Choice 2: her
    Choice 3: his

3. Description - UTI XVI722 (DPS UTI ATY024) - Fee Amount Unknown - Fee Agreement Approved By the Office of Hearings and Appeals (ODAR)

We wrote you before and said we had approved the fee agreement between (1) and (2) (3). Once we complete all our actions on (4) Social Security claim, we will decide the amount of the fee, if any, (5) (6) can charge (7) for the work on (8) Supplemental Security Income (SSI) claim. We will send you another letter about SSI telling you the amount of the fee, if any, (9) (10) can charge (11) for the work on (12) SSI claim.

Fill-Ins:

  1. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  2. Choice 1: your
    Choice 2: her
    Choice 3: his

  3. Choice 1: lawyer
    Choice 2: representative

  4. Choice 1: your
    Choice 2: her
    Choice 3: his

  5. Choice 1: your
    Choice 2: her
    Choice 3: his

  6. Choice 1: lawyer
    Choice 2: representative

  7. Choice 1: you
    Choice 2: her
    Choice 3: him

  8. Choice 1: your
    Choice 2: her
    Choice 3: his

  9. Choice 1: your
    Choice 2: her
    Choice 3: his

  10. Choice 1: lawyer
    Choice 2: representative

  11. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  12. Choice 1: your
    Choice 2: her
    Choice 3: his

G. Exhibit - Interim Assistance Reimbursement (IAR) Involved - First Check Sent To State Agency

Description - UTI XVI528 (DPS Caption CHKC07 and UTI CHK002) - Title XVI Record Shows GR Code (IAR Involved) - Representative Not Eligible for Direct Payment

We Sent (1) First Check To The State

We wrote you before and said we had sent (2) first Supplemental Security Income check for past months to (3). This is because (4) agreed in writing to have us send (5) first check to that agency. We also said the State would send (6) any money they may owe (7).

Fill-Ins:

  1. Choice 1: Your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3 TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  2. Choice 1: your
    Choice 2: her
    Choice 3: his

  3. TEXT FILL (Name of State agency)

  4. Choice 1: you
    Choice 2: she
    Choice 3: he

  5. Choice 1: your
    Choice 2: her
    Choice 3: his

  6. Choice 1: you
    Choice 2: her
    Choice 3: him

  7. Choice 1: you
    Choice 2: her
    Choice 3: him

H. Exhibit - Administrative Review

1. Description - UTI XVI727 (DPS Caption ATYC02, UTI FEE052, Caption FEEC09, and UTI FEE056) - Procedure for Review of Fee Resulting From Agreement

How to Ask Us to Review The Fee
You, (1) (2) or the person who decided (3) case can ask us to review the amount of the fee we say (4) (5) 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:

Social Security Administration
Office of Hearings and Appeals
Attorney Fee Branch
5107 Leesburg Pike
Falls Church, Virginia 22041-3255

(6) (7) 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 (8) (9), we will assume you both agree with the amount of the fee shown.

What Happens When We Review The Amount of the Fee

If we are asked to review the amount of the fee, the following things will happen.

  • We will tell you, (10) (11) and the person who decided (12) case that we are reviewing the amount of the fee.

  • We will make a decision about the amount of the fee.

  • We will write and tell you, (13) (14) and the person who decided (15) case if the amount of the fee changes or stays the same.

Fill-Ins:

  1. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  2. Choice 1: lawyer
    Choice 2: representative

  3. Choice 1: your
    Choice 2: her
    Choice 3: his

  4. Choice 1: your
    Choice 2: her
    Choice 3: his

  5. Choice 1: lawyer
    Choice 2: representative

  6. Choice 1: Your
    Choice 2: Her
    Choice 3: His

  7. Choice 1: lawyer
    Choice 2: representative

  8. Choice 1: your
    Choice 2: her
    Choice 3: his

  9. Choice 1: lawyer
    Choice 2: representative

  10. Choice 1: your
    Choice 2: her
    Choice 3: his

  11. Choice 1: lawyer
    Choice 2: representative

  12. Choice 1: your
    Choice 2: her
    Choice 3: his

  13. Choice 1: your
    Choice 2: her
    Choice 3: his

  14. Choice 1: lawyer
    Choice 2: representative

  15. Choice 1: your
    Choice 2: her
    Choice 3: his

2. Description - UTI XVI728 (DPS Caption ATYC02, UTI ATY817, Caption ATYC09, and UTI FEE093) - Procedure for Review of the Disapproval of a Fee Agreement

How to Ask Us to Review the Determination on the Fee Agreement

You or (1) (2) 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:

Social Security Administration
Office of Hearings and Appeals
Attorney Fee Branch
5107 Leesburg Pike
Falls Church, Virginia 22041-3255

(3) (4) also has 15 days to write us if he or she does not agree with the determination on the fee agreement.

What Happens When We Review the Determination on the Fee Agreement

If we are asked to review the determination on the fee agreement, the following things will happen.

  • We will tell you, (5) (6) and the person who decided (7) case that we are reviewing the determination on the fee agreement.

  • We will make a new determination on the fee agreement.

  • We will write and tell you, (8) (9) and the person who decided (10) case if the determination on the fee agreement changes or stays the same.

Fill-Ins:

  1. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  2. Choice 1: lawyer
    Choice 2: representative

  3. Choice 1: Your
    Choice 2: Her
    Choice 3: His

  4. Choice 1: lawyer
    Choice 2: representative

  5. Choice 1: your
    Choice 2: her
    Choice 3: his

  6. Choice 1: lawyer
    Choice 2: representative

  7. Choice 1: your
    Choice 2: her
    Choice 3: his

  8. Choice 1: your
    Choice 2: her
    Choice 3: his

  9. Choice 1: lawyer
    Choice 2: representative

  10. Choice 1: your
    Choice 2: her
    Choice 3: his

3. Description - DPS UTI FEE077 - Procedure for Review of Fee Resulting From Agreement - Spouse’s Benefits Involved

How to Ask Us to Review the Fee

You, (1) spouse, the (2), or the person who decided (3) case can ask us to review the amount of the fee we say the (4) 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 the reasons. Send the request to this address:

Social Security Administration
Office of Hearings and Appeals
Attorney Fee Branch
5107 Leesburg Pike
Falls Church, VA 22041-3255

The (5) 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 anyone who can ask us to review the amount of the fee, we will assume all agree with the amount of the fee shown.

What Happens When We Review the Amount of the Fee

If we are asked to review the amount of the fee, the following things will happen.

  • We will tell you, (6) spouse, the (7), and the person who decided (8) case that we are reviewing the amount of the fee.

  • We will make a decision about the amount of the fee.

  • We will write and tell you, (9) spouse, the (10), and the person who decided (11) case if the amount of the fee changes or stays the same.

Fill-Ins:

  1. Choice 1: your
    Choice 2: TEXT FILL’s (Enter recipient's name if the notice is for recipient’s representative payee and name ends with other than -s, -x, -z)
    Choice 3: TEXT FILL’ (Enter recipient's full name if letter to recipient’s representative payee and name ends in -s, -x, or -z)

  2. Choice 1: lawyer
    Choice 2: representative

  3. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  4. Choice 1: lawyer
    Choice 2: representative

  5. Choice 1: lawyer
    Choice 2: representative

  6. Choice 1: your
    Choice 2: TEXT FILL’s (Enter recipient's full name if notice is for the recipient’s payee and the name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter recipient's name if notice is for recipient’s representative payee and the name ends in -s, -x, or -z)

  7. Choice 1: lawyer
    Choice 2: representative

  8. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  9. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient's full name if letter to recipient’s payee and name ends in other than -s, -x, or -y)
    Choice 3: TEXT FILL’ (Enter recipient's full name if notice is for recipient’s representative payee and name ends in -s, -x, or -z)

  10. Choice 1: lawyer
    Choice 2: representative

  11. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

I. Exhibit - Past-Due Benefits Withheld For Direct Payment - Fee Agreement Approved

1. Description - Caption FEEC11 (DPS Caption ATYC03)

Information About Past-Due Benefits Withheld to Pay (1) (2)

Fill-Ins:

  1. Choice 1: Your
    Choice 2: Her
    Choice 3: His

  2. Choice 1: Lawyer
    Choice 2: Representative

2. Description - UTI FEE035 (DPS UTI FEE035) - Past-Due Benefits Withheld

(1) is eligible to receive direct payment of the fee we approve. Because of the law, we usually withhold part of the past-due benefits to pay an approved (2) fee. We withheld money from (3) past-due benefits to pay (4).

Fill-Ins:

  1. Choice 1: Your lawyer
    Choice 2: Her lawyer
    Choice 3: His lawyer
    Choice 4: Your representative
    Choice 5: Her representative
    Choice 6: His representative

  2. Choice 1: lawyer’s
    Choice 2: representative’s

  3. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient’s name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient’s name ends with -s, -x, or -z)

  4. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

3. Description - DPS UTI FEE107 - SSI Past-Due Benefits Amount and Period

(1)  SSI past-due benefits are (2) for (3).

Fill-Ins:

  1. Choice 1: Your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  2. MONEY FILL (Amount of past-due benefits)

  3. Choice l: DATE FILL (Month/Year)
    Choice 2: DATE FILL (Month/Year) through DATE FILL (Month/Year)

4. Description - DPS UTI FEE108 - Withheld Past-Due Benefits Amount

We withheld (1) from the past-due benefits.

Fill-Ins:

  1. MONEY FILL (Amount withheld from past-due benefits)

5. Description - DPS UTI FEE078 - Benefits Withheld from Spouse’s Past-Due Benefits

In addition, we withheld money from (1) spouse’s past-due benefits to pay the (2).

Fill-Ins:

  1. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  2. Choice 1: lawyer
    Choice 2: representative

6. Description - DPS UTI FEE067 - Benefits Withheld from Spouse’s Past-Due Benefits for Authorization Based on Fee Petition

In addition, because (1) (2)’s work resulted in (3), we withheld part of (4) spouse’s past-due benefits to pay the (5).

Fill-Ins:

  1. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  2. Choice 1: lawyer
    Choice 2: representative

  3. Choice 1: an increase in your spouse’s SSI
    Choice 2: an increase in her spouse’s SSI
    Choice 3: an increase in his spouse’s SSI
    Choice 4: your spouse becoming eligible for SSI
    Choice 5 her spouse becoming eligible for SSI
    Choice 6: his spouse becoming eligible for SSI

  4. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  5. Choice 1: lawyer
    Choice 2: representative

7. Description - DPS UTI FEE079 - Benefits Withheld from Spouse’s Past-Due Benefits and Fee Being Paid from Those Benefits

In addition, we withheld part of (1) spouse’s past-due benefits to pay the (2). We are paying $ (3) of the approved fee to the (4) now.

Fill-Ins:

  1. Choice 1: your
    Choice 2: TEXT FILL’s (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  2. Choice 1: lawyer
    Choice 2: representative

  3. MONEY FILL (Amount of fee paid to representative from spouse’s past-due benefits)

  4. Choice 1: lawyer
    Choice 2: representative

8. Description - UTI FEE039 (DPS UTI FEE039) - Past-Due Benefits Withheld - Fee Not Authorized

When the amount of the fee is decided, we will let (1) and (2) know how much of this money we use to pay the fee. We will send any remainder to (3). 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.

Fill-Ins:

  1. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  2. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

  3. Choice 1: you
    Choice 2: her
    Choice 3: him

9. Description - UTI FEE040 (DPS UTI FEE040) - Past-Due Benefits Withheld - IAR Amount Pending

(1) is eligible to receive direct payment of the fee we approve. Because of the law, we usually withhold part of the past-due benefits to pay an approved (2) fee. If any money is left after we repay the (3), we will pay as much of the approved fee as we can to (4). Then, if any money is left from (5) first payment after we pay the fee, we will send it to (6).

If we pay only part or none of the approved fee to (7), payment of the amount we do not pay will be a matter between (8) and (9).

Fill-Ins:

  1. Choice 1: Your lawyer
    Choice 2: Her lawyer
    Choice 3: His lawyer
    Choice 4: Your representative
    Choice 5: Her representative
    Choice 6: His representative

  2. Choice 1: lawyer’s
    Choice 2: representative’s

  3. TEXT FILL (Name of State Agency)

  4. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

  5. Choice 1: your
    Choice 2: TEXT FILL’S (Enter the recipient’s name if the notice is for the representative payee and recipient’s name ends with other than -s, -x, or -z)
    Choice 3: TEXT FILL’ (Enter the recipient’s name if the notice is for the representative payee and recipient's name ends with -s, -x, or -z)

  6. Choice 1: you
    Choice 2:  TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  7. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

  8. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  9. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

10. Description - UTI FEE041 (DPS UTI 041) - IAR Paid - Introduction to Fee Payment

(1) agreed in writing that the (2) would be repaid the money it paid (3). We paid the (4) (5). We also told (6) that we would pay the approved fee to (7) (8).

Fill-Ins:

  1. Choice 1: As we told you in another letter, you
    Choice 2: As we told you in another letter, she
    Choice 3: As we told you in another letter, he
    Choice 4: You
    Choice 5: She
    Choice 6: He

  2. TEXT FILL (Name of State agency)

  3. Choice 1: you
    Choice 2: her
    Choice 3: him

  4. TEXT FILL (Name of State agency)

  5. MONEY FILL (Amount paid to State agency)

  6. Choice 1: you
    Choice 2: her
    Choice 3: him

  7. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

  8. Choice 1: if we could
    Choice 2: Null

11. Description - UTI FEE042 (DPS UTI 042) - IAR Paid - No Payment to Representative

However, there was no money left to pay the fee. Payment of the approved fee is a matter between (1) and (2).

Fill-Ins:

  1. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  2. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

12. Description - UTI FEE043 (DPS UTI FEE043) - IAR Paid - Partial Fee Paid to Representative

We are paying (1) (2) from the benefits we withheld. Payment of the remainder of the approved fee, (3), is a matter between (4) and (5).

Fill-Ins:

  1. Choice 1: you lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

  2. MONEY FILL (Amount paid to representative before deducting any assessment)

  3. MONEY FILL (Amount of authorized fee SSA is not paying to the representative)

  4. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  5. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

13. Description - UTI FEE044 (DPS UTI FEE044) - IAR Paid - Fee Paid to Representative - Nothing Left to Pay Claimant

We are paying (1) (2), the amount of the approved fee from the benefits we withheld. There are no benefits left to pay (3).

Fill-Ins:

  1. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

  2. MONEY FILL (Amount of authorized fee)

  3. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

14. Description - UTI FEE045 (DPS FEE045) - IAR Paid - Fee Paid - Remainder to Claimant

We are paying (1) (2), the amount of the approved fee from the benefits we withheld. We have (3) left to pay (4).

Fill-Ins:

  1. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

  2. MONEY FILL (Amount of authorized fee)

  3. MONEY FILL (Amount of past-due benefits SSA is paying to recipient)

  4. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

15. Description - UTI FEE046 (DPS UTI FEE080) - Fee Paid

We are paying (1) from the benefits we withheld.

Fill-Ins:

  1. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

J. Exhibit - Past-Due Benefits Withheld - Fee Agreement Disapproved

1. Description - DPS UTI FEE085 - Time limit for Filing Fee Petition and Be Paid Directly

If (1) (2) wants us to pay the fee we approve from (3) withheld benefits, he or she must ask us to approve the fee within 60 days of the date of this letter.

  • If all the work on this case is finished, and the (4) wants to charge a fee, he or she should send us a request to approve it right away.

  • If all work is not finished in this case, the (5) should let us know within 60 days of the date of this letter that he or she will ask for a fee.

  • If the (6) 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 send us a signed and dated statement saying so right away.

Fill-Ins:

  1. Choice 1: your
    Choice 2: her
    Choice 3: his

  2. Choice 1: lawyer
    Choice 2: representative

  3. Choice 1: your
    Choice 2: her
    Choice 3: his

  4. Choice 1: lawyer
    Choice 2: representative

  5. Choice 1: lawyer
    Choice 2: representative

  6. Choice 1: lawyer
    Choice 2: representative

2. Description - DPS UTI FEE087 - Where to Send Petition

The (1) should send any request for fee approval to:

(2).

Fill-Ins:

  1. Choice 1: lawyer
    Choice 2: representative

  2. TEXT FILL

    • Processing Center with jurisdiction - initial and reconsideration level cases

    • Servicing hearing office address if ALJ approved fee agreement and approval rescinded because there are no past-due benefits

    • Other cases when ODAR approved fee agreement:

      Office of Hearings and Appeals
      Attorney Fee Branch, Suite 805
      5107 Leesburg Pike
      Falls Church, VA 22041-3255

K. Exhibit - Assessment When Paying Fee To Representative

1. Description - UTI FEE047 (DPS UTI FEE047) - Title XVI Only

Because we are paying the fee from (1) benefits, we must collect a service charge from (2). The service charge is 6.3 percent of the fee amount we pay, but not more than (3), which is the most we can collect in each case under the law. We will subtract the service charge from the amount payable to (4). This means that we subtract (5) from the (6) we are paying toward the (7) fee, and send him or her (8).

(9) cannot ask (10) to pay for the service charge. If (11) disagrees with the amount of the service charge, he or she must write to the address shown below. (12) must tell us why he or she disagrees within 15 days from the day he or she gets this letter.

Fill-Ins:

  1. Choice 1: your
    Choice 2: her
    Choice 3: his

  2. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

  3. MONEY FILL (The amount of the assessment cap)

  4. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

  5. MONEY FILL (Amount of assessment)

  6. MONEY FILL (Fee amount payable from past-due benefits before assessment deducted)

  7. Choice 1: lawyer’s
    Choice 2: representative’s

  8. MONEY FILL (Amount of fee payment to representative after deducting assessment)

  9. Choice 1: Your lawyer
    Choice 2: Her lawyer
    Choice 3: His lawyer
    Choice 4: Your representative
    Choice 5: Her representative
    Choice 6: His representative

  10. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  11. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

  12. Choice 1: Your lawyer
    Choice 2: Her lawyer
    Choice 3: His lawyer
    Choice 4: Your representative
    Choice 5: Her representative
    Choice 6: His representative

2. Description - UTI FEE048 (DPS UTI FEE048) - Second Fee Payment - Additional Assessment

Because we are paying the fee from (1) benefits, we must collect a service charge from (2). The service charge is 6.3 percent of the fee amount we pay, but not more than (3), which is the most we can collect in each case under the law. We previously paid a fee and collected a service charge that was less than (4). This means that we now subtract (5) from the (6) we are paying toward the (7) fee and send him or her (8).

(9) cannot ask (10) to pay for the service charge. If (11) disagrees with the amount of the service charge, he or she must write to the address shown below. (12) must tell us why he or she disagrees within 15 days from the day he or she gets this letter.

Fill-Ins:

  1. Choice 1: your
    Choice 2: her
    Choice 3: his

  2. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative Choice 6: his representative

  3. MONEY FILL (The amount of the assessment cap)

  4. MONEY FILL (The amount of the assessment cap)

  5. MONEY FILL (Amount of additional assessment)

  6. MONEY FILL (Fee amount payable from past-due benefits before assessment deducted)

  7. Choice 1: lawyer’s
    Choice 2: representative’s

  8. MONEY FILL (Amount of fee payment to representative after deducting assessment)

  9. Choice 1: Your lawyer
    Choice 2: Her lawyer
    Choice 3: His lawyer
    Choice 4: Your representative
    Choice 5: Her representative
    Choice 6: His representative

  10. Choice 1: you
    Choice 2: TEXT FILL (If the notice is for the representative payee, enter the recipient’s name)

  11. Choice 1: your lawyer
    Choice 2: her lawyer
    Choice 3: his lawyer
    Choice 4: your representative
    Choice 5: her representative
    Choice 6: his representative

  12. Choice 1: Your lawyer
    Choice 2: Her lawyer
    Choice 3: His lawyer
    Choice 4: Your representative
    Choice 5: Her representative
    Choice 6: His representative

3. Description - UTI FEE049 (DPS UTI FEE049) - Fee Assessment Cap Reached - No Additional Assessment

When we pay the fee from benefits, we usually must collect a service charge of 6.3 percent of the fee amount we pay, but not more than (1), which is the most we can collect in each case under the law. Because we paid a fee and collected the full (2) before, there is no additional charge.

Fill-Ins:

  1. MONEY FILL (The amount of the assessment cap)
    MONEY FILL (The amount of the assessment cap)

4. Description - DPS UTI FEE081 - Multiple Representatives

(1) Because we are paying the fee from (2) benefits, we must collect a service charge from each representative. The service charge is 6.3 percent of the fee amount we pay, but not more than (3), which is the most we can collect in each case under the law. When 6.3 percent of the combined payments exceeds (4), we divide the (5) service charge based on the individual fee amounts. We will subtract part of the service charge from the fee amount payable to each representative.

A representative cannot ask you to pay for the service charge. If a representative disagrees with the amount of the service charge, he or she must write to the address shown at the top of this letter. The representative must tell us why he or she disagrees within 15 days from the day he or she gets this letter.

Fill-Ins:

  1. Choice 1: We will send you the balance of the amount we withheld.
    Choice 2: Null (No benefits remaining to pay to recipient)

  2. Pronoun (your/his/her/Client Name Possessive)

  3. Choice 1: $93.00
    Choice 2: $91.00
    Choice 3: $89.00

  4. Choice 1: $93.00
    Choice 2: $91.00
    Choice 3: $89.00

  5. Choice 1: $93.00
    Choice 2: $91.00
    Choice 3: $89.00

5. Description - DPS UTI FEE082 - Assessment Recalculated

Previously, we paid you a fee of $(1). As required by law, we reduced the fee payment amount by a service charge of $(2), which was the lower of 6.3 percent of the fee we paid or (3).

Later, we authorized a fee on the same claim to another representative eligible to receive direct payment. When 6.3 percent of the combined payments exceeds (4), we divide the (5) service charge based on the individual fee amounts. Therefore, we have recalculated the service charge and are refunding $(6) to you.

Fill-Ins:

  1. MONEY FILL (Amount of payment made to representative after deducting assessment)

  2. MONEY FILL (Amount of assessment)

  3. Choice 1: $93.00
    Choice 2: $91.00
    Choice 3: $89.00

  4. Choice 1: $93.00
    Choice 2: $91.00
    Choice 3: $89.00

  5. Choice 1: $93.00
    Choice 2: $91.00
    Choice 3: $89.00

  6. MONEY FILL (Amount of excess assessment)

L. Exhibit - Representative Eligible for Direct Payment Waives Fee

1. Description - DPS UTI FEE073 - Benefits Not Withheld for Fee Payment Because Representative Waived Fee

(1) (2) is eligible for direct payment of the fee we approve. Because of the law, we usually withhold part of the past-due benefits to pay an approved fee (3)’s fee. However, the (4) has told us he or she will not charge a fee for services on this claim. For this reason, we have not withheld any past-due benefits to pay the (5).

Fill-Ins:

  1. Choice 1: Your
    Choice 2: Her
    Choice 3: His

  2. Choice 1: lawyer
    Choice 2: representative

  3. Choice 1: lawyer
    Choice 2: representative

  4. Choice 1: lawyer
    Choice 2: representative

  5. Choice 1: lawyer
    Choice 2: representative

2. Description - UTI FEE075 - Representative Must Request Fee Approval

If (1) (2) wants to charge a fee, he or she must ask us in writing to approve the fee. The (3) must give you a copy of his or her fee request and each attachment to the request.

Fill-Ins:

  1. Choice 1: your
    Choice 2: her
    Choice 3: his

  2. Choice 1: lawyer
    Choice 2: representative

  3. Choice 1: lawyer
    Choice: 2: representative


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0203940085
GN 03940.085 - Title XVI Fee Agreement Paragraphs - 11/09/2017