We are writing to let you know that (1) has been approved to collect a fee from (2) monthly benefits for serving as (3) representative payee. They can begin collecting these fees in (4) .

What (5) Representative Payee Can Collect

(6) representative payee may collect a fee of 10 percent of (7) total monthly benefits, but no more than $ (8) each month.

If You Have Any Questions

3765C

• •

  Send this notice to inform a legally competent adult, emancipated minor, legal guardian, or parent or person standing in place of parent when the representative payee has been authorized to collect a fee.

• •

  Show the title of the officer and the name of the institution or entity. Do not show the name of such officer.

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  Refer to NL 00703.765 for 3765C text and fill-ins.

• •

  The fee amounts for fill-in (8) will change each year beginning 1996, subject to the Consumer Price Index.

   

Fill-ins:

1. (1) 

   Name of representative payee

2. (2) 

   your, name of beneficiary (possessive)

3. (3) 

   your, his, her

4. (4) 

   month/year organization can begin collecting fees from this beneficiary

5. (5) 

   Your, His, Her

6. (6) 

   Your, first name of beneficiary (possessive)

7. (7) 

   your, his, her

8. (8) 

   maximum non-DAA amount, maximum DAamount

This notice will be sent by the FO. It may be reproduced on FO letterhead.