TN 17 (03-05)

GN 03940.090 Fee Authorization Under the Fee Agreement Process - Exhibits

A. List of Exhibits

The exhibits are as follows:

  • Exhibit 1 Model Fee Agreement Language

  • Exhibit 2 Sample Language for Fee Agreement Determination (Form SSA-553 (Special Determination))

  • Exhibit 3 Regional Chief Administrative Law Judges' Addresses and Codes of the Hearing Offices Within Their Jurisdictions

  • Exhibit 4 Sample Follow-up Memorandum to Hearing Office Director with a cc to the ALJ, or to the AAJ with a cc: to the Deputy Chair, Appeals Council - No Fee Agreement Determination

  • Exhibit 5 Memorandum to Regional Chief ALJ - Fee Agreement Approved Incorrectly - ALJ Hearing Level

  • Exhibit 6 Memorandum to Deputy Chair, Appeals Council - Fee Agreement Approved Incorrectly - Appeals Council Review Level

B. Exhibit 1 - Model Fee Agreement Language

Fee for Services

My representative and I understand that, for a fee to be payable, the Social Security Administration (SSA) must approve any fee my representative charges or collects from me for services my representative provides in proceedings before SSA in connection with my claim(s) for benefits.

We agree that, if SSA favorably decides the claim(s), I will pay my representative a fee equal to the lesser of (1) percent of the past-due benefits resulting from my claim(s) or $(2).

Review of the Fee

We understand that one or both of us may request review of the fee amount, in writing, within 15 days after SSA has notified us of any amount my representative can charge.

  • My representative may ask SSA to increase the fee, and (3) has informed me (4) will do so if (5).

  • I may ask SSA to reduce the fee.

  • An affected auxiliary Social Security beneficiary, if any, may ask SSA to reduce the fee too.

  • Also, if SSA approved the fee agreement, the person(s) who decided my claim(s) may ask for a reduction of the fee under the agreement if, in his or her opinion, my representative did not represent my interests adequately or the fee is clearly excessive for the services provided.

If someone requests review, SSA generally would send the other(s) a copy and offer an opportunity to comment on the request and provide more information to the person reviewing the request. SSA then would finally decide the amount of the fee and notify us in writing whether the fee increased, decreased, or did not change.

We both have received signed copies of this agreement.

Fill-in(s):

(1) A number less than or equal to 25

(2) A number less than or equal to the applicable maximum dollar limit established pursuant to section 206(a)(2)(A) of the Social Security Act (e.g., $5,300, $6,000)

(3) Choice 1 - he

Choice 2 - she

(4) Same as (3) above

(5) Explanation of the conditions under which the representative might seek a fee higher than the fee otherwise agreed upon

C. Exhibit 2 - Sample Language For Fee Agreement Determination (Form SSA-553 (Special Determination))

I. FEE AGREEMENT APPROVED:

I approve the fee agreement between the claimant and his or her representative provided that the claim results in past-due benefits.

My determination is limited to whether the fee agreement meets the statutory condition for approval and is not otherwise excepted.

I neither approve nor disapprove any other aspect of the fee agreement.

II. FEE AGREEMENT DISAPPROVED:

I do not approve the fee agreement between the claimant and his or her representative because:

[Check only those that apply]

____

SSA did not receive the written agreement before deciding the claim.

____

The claimant and his/her representative(s) all did not sign the fee agreement.

____

The fee agreement sets a fee that is more than the lesser of 25 percent of the past-due benefits or the applicable specified dollar amount of the fee cap as outlined in GN 03940.003A.3 (e.g. $5300, $6000).

____

The claimant appointed more than one representative from a firm, partnership, or legal corporation, all did not sign a single fee agreement, and the non-signing representative(s) did not waive charging or collecting a fee.

____

The claimant appointed representatives who are not members of a single firm, partnership, or legal corporation, and the non-signing representative(s) did not waive charging or collecting a fee.

____

The claimant discharged a representative, or a representative withdrew from the case before SSA decided the claim, and the representative did not waive charging or collecting a fee.

____

A State court declared the claimant legally incompetent and the claimant's legal guardian did not sign the fee agreement.

____

There are no past-due benefits.

Prior/Subsequent Applications with Multiple Representatives

____

Considering the appointments of representative in the claimant's applications dated [Date of prior application] and [Date of subsequent application], the claimant appointed more than one representative from a firm, partnership, or legal corporation, all did not sign a single fee agreement, and the non-signing representative(s) did not waive charging or collecting a fee.

____

Considering the appointments of representative in the claimant's applications dated [Date of prior application] and [Date of subsequent application], the claimant appointed representatives who are not members of a single firm, partnership, or legal corporation, and the non-signing representative(s) did not waive charging or collecting a fee.

____

Considering the appointments of representative in the claimant's applications dated [Date of prior application] and [Date of subsequent application], the claimant has been declared legally incompetent and the claimant's legal guardian did not sign the fee agreement.

D. Exhibit 3 - Regional Chief Administrative Law Judges' Addresses and Codes of the Hearing Offices within their Jurisdictions

NOTE: For a National Hearing Center (NHC) case, send any protest memoranda to the Office of the Regional Chief Administrative Law Judge that has jurisdiction over the region where the claimant is currently residing.

ADDRESSES OF THE OFFICES OF THE REGIONAL CHIEF ADMINISTRATIVE LAW JUDGES

HEARING OFFICE CODES WITHIN THEIR JURISDICTIONS:

Region I

(Boston) (5150)

E-Mail: ||ODAR R1 BOSTON RO


5018, 5019, 5105, 5134, 5182, 5302, 5305 and 5384

Region II

(New York) (5025)

E-mail: ||ODAR R2 NEW YORK RO


5020, 5021, 5023, 5024, 5028, 5092, 5102, 5108, 5109, 5110, 5135, 5200, 5308, 5310, 5312 and 5391

Region III

(Philadelphia) (5038)

E-mail: ||ODAR R3 PHILADELPHIA RO

5026, 5029, 5030, 5031, 5033, 5034, 5035, 5036, 5037, 5103, 5104, 5112, 5136, 5252, 5253, 5320, 5321 and 5322

Region IV

(Atlanta) (5054)

E-mail: ||ODAR R4 ATLANTA RO

5027, 5032, 5039, 5040, 5041, 5042, 5043, 5044, 5045, 5046, 5047, 5048, 5049, 5050, 5051, 5052, 5053, 5091, 5094, 5106, 5113, 5115, 5116, 5117, 5137, 5138, 5139, 5140, 5175, 5199, 5204, 5245, 5372, 5381, 5383, 5385, 5390 and 5397

Region V

(Chicago) (5063)

E-mail: ||ODAR R5 CHICAGO RO

5055, 5056, 5057, 5058, 5059, 5060, 5061, 5062, 5065, 5095, 5118, 5119, 5120, 5121, 5122, 5141, 5189, 5201, 5202, 5208, 5365, 5373, 5380, 5387 and 5398

Region VI

(Dallas) (5078)

E-mail: ||ODAR R6 Dallas RO

5070, 5071, 5072, 5073, 5074, 5075, 5076, 5077, 5124, 5125, 5133, 5143, 5153, 5181, 5254, 5255 and 5374

Region VII

(Kansas City) (5069)

E-mail : ||ODAR R7 KANSAS CITY RO

5064, 5066, 5067, 5068, 5127, 5144, 5224, 5375 and 5389

Region VIII

(Denver) (5151)

E-mail: ||ODAR R8 DENVER RO

5079, 5128, 5145, 5167, 5192, 5376 and 5395

Region IX

(San Francisco) (5088)

E-mail: ||ODAR R9 SAN FRANCISCO RO

5080, 5081, 5083, 5085, 5086, 5087, 5090, 5096, 5097, 5100, 5101, 5129, 5130, 5131, 5147, 5148, 5193, 5257, 5377, 5379, 5382, 5388 and 5392

Region X

(Seattle) (5152)

E-mail: ||ODAR RX SEATTLE RO

5082, 5084, 5132, 5149, 5371 and 5386

E. Exhibit 4 - Sample Follow-up Memorandum to Hearing Office Director with a CC to the ALJ or to the AAJ with a CC to the Deputy Chair, Appeals Council - No Fee Agreement Determination

MEMORANDUM TO:

(Name of the Hearing Office Director)
(City in which the hearing office is located)

or

(Name of AAJ)
Administrative Appeals Judge
Through: Attorney Fee Branch
Office of Disability Adjudication and Review
5107 Leesburg Pike, Suite 805 Skyline
Falls Church, Virginia 22041-3255

FROM:

(Title of PC Official)
(PC Involved, e.g., NEPSC, ODO)

SUBJECT:

Determination on Fee Agreement - ACTION

(Claimant's Name and SSN);

On (Date of telephone contact), we advised (the [specify which hearing office] hearing office/your office) by (telephone/fax/e-mail) that the file in the subject claim does not contain a determination on the fee agreement in this case. We asked (the hearing office/your office) to forward a determination on the fee agreement to us within 15 days.

We are unable to authorize a fee for the representative's services until we receive a determination on the fee agreement.

[Use the following paragraph if the representative is an attorney and SSA is withholding past-due benefits for direct fee payment:]

We are withholding $(Amount of past-due benefits withheld for direct payment) of the claimant's past-due benefits for direct payment of a fee to the representative. However, we cannot release any of the withheld funds until we receive the determination on the fee agreement.

Please (request the ALJ to) fax the determination to us as soon as possible (fax number [fax number]). If you have any questions, please contact (Name of PC contact) at (Telephone number of PC contact).

 

(Signature of PC Official)

(Printed Name of PC Official)

cc:  [(If addressee is HOD) ALJ]
      [(If addressee is AAJ) Deputy Chair, Appeals Council]

Attachments

F. Exhibit 5 - Memorandum to Regional Chief ALJ - Fee Agreement Approved Incorrectly - ALJ Hearing Level

MEMORANDUM TO:

Regional Chief Administrative Law Judge

(Address)

FROM:


(Title of PC Official)

(PC Name and Address)

SUBJECT:

Fee Agreement Determination - ACTION

(Claimant's Name and SSN)

On (date), Administrative Law Judge (name) signed an order approving the fee agreement in this case. We do not believe that the approval is correct for the following reason(s). (List Reason(s).)

Copies of the favorable decision, the appointment(s) of representative(s), the fee agreement(s), the order approving the fee agreement, and (any additional relevant information) are available in the electronic folder for your review and action.

We are withholding $(amount) of the claimant's past-due benefits for direct payment to the representative.

Please email your determination to us as soon as possible (email address). If you have any questions, please contact (name of contact) at (contact number/email address).

 

                                              

 

(Signature of PC Official)

 

(Name Printed)

Attachments

G. Exhibit 6 - Memorandum to Deputy Chair, Appeals Council - Fee Agreement Approved Incorrectly - Appeals Council Review Level

MEMORANDUM TO:

Deputy Chair, Appeals Council
Office of Disability Adjudication and Review
5107 Leesburg Pike, Suite 1400 Skyline
Falls Church, Virginia 22041-3255

FROM:


(Title of PC Official)

(PC Name and Address)

SUBJECT:

Fee Agreement Determination - ACTION
(Claimant's Name and SSN)

On (date), Administrative Appeals Judge (name of AAJ) signed an order approving the fee agreement in this case. We do not believe that the approval is correct for the following reason(s). (Reasons.)

Copies of the favorable decision, the appointment(s) of representative(s), the fee agreement(s), the order approving the fee agreement, and (any additional relevant information) are available in the electronic folder for your review and action.

We are withholding $____ of the claimant's past-due benefits for direct payment to the representative.

Please send your determination to us as soon as possible. If you have any questions, please contact us at (contact information).

 

                                              

 

(Signature of PC Official)

 

(Name Printed)

Attachments


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0203940090
GN 03940.090 - Fee Authorization Under the Fee Agreement Process - Exhibits - 06/20/2017
Batch run: 06/20/2017
Rev:06/20/2017