TN 41 (09-04)
NL 00703.943 Notice Authorizing Organization to Collect a Fee
(See GN 00506.130B. for fee for service notification policy and procedures)
Document Identifier for Word Processor: E3943
A. EXHIBIT LETTER
You are authorized to collect a fee for serving as representative payee for Social Security and Supplemental Security Income beneficiaries. You may collect these fees from payments received for months beginning (1) . You may continue to do so unless we revoke this authorization in writing or you cancel it in writing.
Since your organization charges for the services it provides to beneficiaries, we consider it a creditor organization. We decide on a case-by-case basis whether a creditor organization can collect a fee for serving as a beneficiary's payee.
We have attached a list of the names of the beneficiaries from whom you may collect fees. Each time your organization applies to be representative payee for other beneficiaries, we will send you a separate letter telling you whether you may collect a fee. We have enclosed more information about this.
Amount of Fee
Your organization may collect a fee of up to 10 percent of the total monthly benefits, up to a maximum of $ (2) per month, from beneficiaries receiving disability benefits, if we have found they have a substance use disorder.
In all other cases, your organization may collect a fee of up to 10 percent of the beneficiary's total monthly benefits, up to a maximum of $ (3) per month.
It is illegal to collect more than these amounts, and you may be fined or imprisoned for doing so.
We have enclosed a list of beneficiaries who receive disability benefits and we have found them to have a substance use disorder.
Our records show you do not serve as representative payee for any beneficiaries who receive disability benefits and we have found them to have a substance use disorder.
We will tell you if our determination about a beneficiary's disability changes, because that could change the amount of the fee you could collect.
Notification to Beneficiaries
We will send a letter to each of the beneficiaries for whom your organization serves as payee. The letter will let him or her know that your organization has been authorized to collect a fee for representative payee services.
Please read the enclosed information about other responsibilities for an organization that we have authorized to collect fees for providing representative payee services.
If You Have Any Questions
List of Beneficiaries for Whom You May Collect Fees (if creditor organization)
List of Beneficiaries Receiving Disability Benefits and We Have Found Them To Have a Substance Use Disorder. (if applicable)
Explanation of Fees for Representative Payee Services
Month, year (format September 2004) that the organization can begin collecting fees. This date must be the latter of the date the organization:
applied in writing to collect a fee,
became payee and received a payment in the month, or
performed payee services
maximum DAA condition amount
maximum non-DAA condition amount
B. REQUESTING INSTRUCTIONS
Use 3943A in letters to creditor organizations.
Use 3943B if the organization is payee for DAA condition beneficiaries.
Use 3943C if the organization does no