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.

 

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 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.

 

Your Responsibilities

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

3765C

 

Enclosures:

• •

  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

 

Fill-ins:

1. (1) 

   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

2. (2) 

   maximum DAA condition amount

3. (3) 

   maximum non-DAA condition amount

 

• •

  The FO will send this notice to an organization which has been authorized by SSA to charge a fee for their services as representative payee.

• •

  Use 3943A in letters to creditor organizations.

• •

  Use 3943B if the organization is payee for DAA condition beneficiaries.

• •

  Use 3943C if the organization does not serve as payee for any DAA beneficiaries.

• •

  Use NL 00703.945 as the enclosure. Also, the list of beneficiaries for whom the organization may collect a fee is optional and will be enclosed only if it is a creditor organization (see GN 00506.130B. for further instructions).

• •

  Refer to NL00703.765 for 3765C text and fill-ins.

The FO will send this notice using FO letterhead.