TN 3 (03-95)

GN 03960.090 Exhibit - Decision Maker Request for Administrative Review and Transmittal




: NE MAT SE GL WN MAM ODIO Processing Center

REGARDING :.     -     -     , 
  Account # & Symbol 
Name of Wage Earner or Beneficary



Request for Administrative Review of Fee Based on an Approved Fee Agreement — ACTION


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.                                                               














        Signature       Date


Attachment(s)   / / Yes    / /No


cc: , Claimaint
  , Representative
  , Auxiliary Beneficary(ies)