TN 4 (08-12)

NL 00720.050 ATY Representative Fee

ATY016 DETERMINATION OF REPRESENTATIVE'S ASSESSMENT AMOUNT – NH, NH AND AUXILIARIES OR AUXILIARIES ONLY – SSA PAYING ONE REPRESENTATIVE, NO PREVIOUS ASSESSMENT (L34)

(Requested)

Caption: Information About Representative's Fees

We are paying the  (1)  from the benefits we withheld. Therefore, we must collect a service charge from him or her. The service charge is 6.3 percent of the fee amount we pay, but not more than $93.00, which is the most we can collect in each case under the law. We will subtract the service charge from the amount payable to the  (2)  .  (3) 

The  (4)  cannot ask you to pay for the service charge. If the  (5)  disagrees with the amount of the service charge, he or she must write to the address shown at the top of this letter. The  (6)  must tell us why he or she disagrees within 15 days from the day he or she gets this letter.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative

Fill-in (2) - Systems Generated

Choice 1: representative

Fill-in (3) – Systems Generated

Choice 1: After we subtract the amount we are paying towards the fee, we will send you the balance of the amount withheld.

Choice 2: Null

Fill-in (4) - Systems Generated

Choice 1: representative

Fill-in (5) - Systems Generated

Choice 1: representative

Fill-in (6) - Systems Generated

Choice 1: representative

ATY054 NO PAST-DUE BENEFITS AVAILABLE — REPRESENTATIVE INVOLVED (A56)

(Requested)

Caption: Information About Representative's Fees

When a representative wants to charge for helping with a Social Security claim, we must first approve the fee. We usually withhold 25 percent of past-due benefits in order to pay the approved representative's fee. However, there are no past-due benefits available to be paid to the representative.

If all work on this case for  (1)  and  (2)  family is finished, and  (3)  representative wants to charge a fee, a request to have it approved should be sent to us right away.

When the amount of the fee is decided, SSA is not involved in paying the fee.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

ATY055 COURT CASE ATTORNEY FEE WITHHOLDING NH ONLY (C15)

(Requested)

Caption: Information About Representative's Fees

 (1)   (2)  may ask the court to approve a fee no larger than 25 percent of past due benefits. Past due benefits are those payable through  (3)  , the month before the court's decision. For this reason, we are withholding  (4)  .

After the court sets the fee, we will let  (5)  and the  (6)  know how much of this money will be used to pay the fee. We will send any remainder to  (7)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: representative

Fill-in (3) - Requested As A Date In Format Shown Below MM/CCYY

Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢

Amount of withholding

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (6) - Systems Generated

Choice 1: representative

Fill-in (7) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

ATY056 COURT CASE ATTORNEY FEE WITHHOLDING FROM NH AND FAMILY (C16)

(Requested)

Caption: Information About Representative's Fees

 (1)   (2)  may ask the court to approve a fee no larger than 25 percent of past due benefits. Past due benefits are those payable to  (3)  and  (4)  family through  (5)  , the month before the court's decision. For this reason, we are withholding  (6)  .

After the court sets the fee, we will let  (7)  and the  (8)  know how much of this money will be used to pay the fee. We will send any remainder to  (9)  and  (10)  family.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: representative

Fill-in (3) – Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (6) - Requested As A Money Amount In Format $$$$$.¢¢

Amount of withholding

Fill-in (7) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (8) - Systems Generated

Choice 1: representative

Fill-in (9) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (10) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

ATY057 NOTICE TO CLAIMANT WHERE A REPRESENTATIVE FEE HAS NOT YET BEEN AUTHORIZED (C18)

(Requested)

Caption: Information About Representative's Fees

When a  (1)  wants to charge for helping with a Social Security claim, we must first approve the fee. We usually withhold 25 percent of past due benefits in order to pay the approved  (2)  fee. We withheld  (3)  from  (4)  past due benefits in case we need to pay  (5)   (6)  .

  • If all the work on this case for  (7)  and  (8)  family is finished, and  (9)   (10)  wants to charge a fee, a request to have it approved should be sent to us right away.

  • If all work is not finished in this case, the  (11)  should let us know that a fee will be charged. This must be done within 60 days of the date of this letter.

  • If the  (12)  will not charge a fee, a statement saying so, signed and dated by the  (13)  , should be sent to us instead.

When the amount of the fee is decided, we will let  (14)  and the  (15)  know how much of this money will be used to pay the fee. We will send any remainder to  (16)  . If the approved fee is more than the money we have withheld, the Social Security Administration is not involved in paying the rest of the fee.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative

Fill-in (2) - Systems Generated

Choice 1: representative

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Amount of withholding

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: representative

Fill-in (7) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (9) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (10) - Systems Generated

Choice 1: representative

Fill-in (11) - Systems Generated

Choice 1: representative

Fill-in (12) - Systems Generated

Choice 1: representative

Fill-in (13) - Systems Generated

Choice 1: representative

Fill-in (14) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (15) - Systems Generated

Choice 1: representative

Fill-in (16) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

ATY058 NOTICE TO CLAIMANT AND FAMILY WHERE ATTORNEY FEE HAS NOT YET BEEN AUTHORIZED (C19)

(Requested)

Caption: Information About Representative's Fees

When a  (1)  wants to charge for helping with a Social Security claim, we must first approve the fee. We usually withhold 25 percent of past due benefits in order to pay the approved  (2)  fee. We withheld  (3)  from the past due benefits of  (4)  and  (5)  family in case we need to pay  (6)   (7)  .

  • If all the work on this case for  (8)  and  (9)  family is finished, and  (10)   (11)  wants to charge a fee, a request to have it approved should be sent to us right away.

  • If all work is not finished in this case, the  (12)  should let us know that a fee will be charged. This must be done within 60 days of the date of this letter.

  • If the  (13)  will not charge a fee, a statement saying so, signed and dated by the  (14)  , should be sent to us instead.

When the amount of that fee is decided, we will let  (15)  and the  (16)  know how much of this money will be used to pay the fee. We will send any remainder to  (17)  and  (18)  family. If the approved fee is more than the money we have withheld, the Social Security Administration is not involved in paying the rest of the fee.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative

Fill-in (2) - Systems Generated

Choice 1: representative's

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Amount of withholding

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: Beneficiary name

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: representative

Fill-in (8) - Systems Generated

Choice 1: you

Choice 2: Beneficiary name

Fill-in (9) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (10) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (11) - Systems Generated

Choice 1: representative

Fill-in (12) - Systems Generated

Choice 1: representative

Fill-in (13) - Systems Generated

Choice 1: representative

Fill-in (14)

Fill-in (15) - Systems Generated

Choice 1: you

Choice 2: Beneficiary name

Fill-in (16) - Systems Generated

Choice 1: representative

Fill-in (17) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (18) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

ATY059 TITLE II/TITLE XVI REPRESENTATIVE FEE AGREEMENT – OFFSET INFORMATION PENDING – NH OR AUXILIARY (IES) (L12)

(Requested)

Caption: What We Will Pay

We are holding  (1)  Social Security benefits for  (2)  . We may have to reduce these benefits if  (3)  received Supplemental Security Income (SSI) for this period. We will not reduce  (4)  past-due benefits if  (5)  did not get SSI benefits for those months.

 (6) 

When we decide how much  (7)  due for this period, we will send  (8)  another letter.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary name possessive

Full-in (2) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6) - Requested As A One Position Alpha Character

Choice 1: (A) However, we will withhold part of any past-due benefits to pay the representative.

Choice 2: (B) Null

Fill-in (7) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (8) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

ATY060 SSI OFFSET INFORMATION PENDING CRITICAL CASE FEE AGREEMENT OR FEE PETITION CASE (L13)

(Requested)

Caption: What We Will Pay

Although we are sending  (1)   (2)  of the money  (3)  due for past months, we are withholding  (4)  Social Security benefits for  (5)  . We may have to reduce these benefits if  (6)  received Supplemental Security Income (SSI) for this period. We will not reduce  (7)  past-due benefits if  (8)  did not get SSI benefits for those months.  (9) 

When we decide how much  (10)  due for this period, we will send  (11)  another letter.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary name

Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢

Amount of payment

Fill-in (3) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/ CCYY through MM/ CCYY

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (9) - Requested As A One Position Alpha Character

Choice 1: (A) However, we will withhold part of any past-due benefits to pay your representative. Later in this letter, we will tell you more about the money we are withholding to pay your representative.

Choice 2: (B) However, we will withhold part of any past-due benefits to pay his representative. Later in this letter, we will tell him more about the money we are withholding to pay his representative.

Choice 3: (C) However, we will withhold part of any past-due benefits to pay her representative. Later in this letter, we will tell her more about the money we are withholding to pay her representative.

Choice 4: (D) Null

Fill-in (10) Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (11) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

ATY061 TITLE II OFFSET APPLIED – CONCURRENT TITLE II/TITLE XVI - FEE AGREEMENT OR FEE PETITION (L22)

(Requested)

Caption: Your Benefits

In an earlier letter, we told  (1)  that we were withholding  (2)  Social Security benefits for  (3)  . We did this because we thought we might have to reduce  (4)  Social Security benefits if  (5)  also received Supplemental Security Income (SSI) money for this period.

Now we are writing to let you know that we cannot pay  (6)   (7)  of the Social Security benefits we withheld. This is because  (8)  received SSI money for  (9)  .

When you receive SSI money for a month, and later you receive Social Security benefits, we sometimes have to reduce your Social Security benefits. We do this to make sure that your total SSI and Social Security monthly payment is not more than it would have been if the Social Security benefits had been paid on time.

 (10)  past-due Social Security benefits are  (11)  for  (12)  . We usually withhold 25 percent of past-due benefits to pay a  (13)  fee. We withheld  (14)  from  (15)  past-due benefits to pay the  (16)  . We are deducting  (17)  from the  (18)  in benefits due for  (19)  . That leaves  (20)  .

Allowing for  (21)  Social Security benefits, we should have paid  (22)   (23)  less in SSI money. We have to take this out of the  (24)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (7) - Requested As A One Position Alpha Character

Choice 1 (A): any

Choice 2 (B): all

Fill-in (8) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (9) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (10) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's Name possessive

Fill-in (11) - Requested As A Money Amount In Format $$$$$.¢¢

Amount of past-due benefits

Fill-in (12) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (13) - Systems Generated

Choice 1: representative's

Fill-in (14) - Requested As A Money Amount In Format $$$$$.¢¢

Attorney fee from past-due benefits

Fill-in (15) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (16) - Systems Generated

Choice 1: representative

Fill-in (17) - Requested As A One Position Alpha Character Or As A Money Amount In Format $$$$$.¢¢

Choice 1: (A) this amount

Choice 2: actual money amount being deducted

Fill-in (18) - Requested As A Money Amount In Format $$$$$.¢¢

Total amount of past-due benefits

Fill-in (19) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (20) - Requested As A Money Amount In Format $$$$$.¢¢

Balance of past-due benefits

Fill-in (21) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (22) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (23) - Requested As A Money Amount In Format $$$$$.¢¢

Amount of Title II benefits that should have been withheld from SSI benefits

Fill-in (24) (Same as Fill-in 20)

Balance of past-due benefits

ATY062 FEE AGREEMENT CASE – CONCURRENT TITLE II/TITLE XVI – REPRESENTATIVE FEE BEING PAID (L23)

(Requested)

Caption: Information About Representative's Fees

We told  (1)  in another letter that the  (2)  could charge  (3)  no more than  (4)  , under the fee agreement, for his or her work on  (5)  Social Security claim. We also said,  (6)  , the  (7)  , or the person who decided  (8)  case could ask us to review the amount of the fee.

We withheld  (9)  from  (10)  benefits to pay the  (11)  . We are sending the  (12)  this money. This means we are paying the  (13)  in full for the work on your Social Security claim.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (2 ) - Systems Generated

Choice 1: representative

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢

Amount

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (7) - Systems Generated

Choice 1: representative

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (9) - Requested As A Money Amount In Format $$$$$.¢¢

Amount withheld

Fill-in (10) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (11) - Systems Generated

Choice 1: representative

Fill-in (12) - Systems Generated

Choice 1: representative

Fill-in (13) - Systems Generated

Choice 1: representative

ATY063 FEE AGREEMENT CASE TITLE II/TITLE XVI FEE MAY CHANGE SSI BENEFITS (Use if FO was not requested to recompute) (L24)

(Requested)

Caption: Your SSI Payments May Change

Because we approved a fee in  (1)  Social Security claim, the amount of benefits we used in figuring  (2)  SSI payments may change. Contact  (3)  local Social Security office to see if we can pay  (4)  more SSI money.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

ATY064 ADDITIONAL FEE AMOUNT – SSI AWARDED – CONCURRENT TITLE II/TITLE XVI (L32)

(Requested)

Caption: Information About Representative's Fees

The  (1)  may be able to charge an additional amount for his or her work on  (2)  Supplemental Security Income (SSI) claim.  (3)  will get another letter, about SSI, telling  (4)  the additional fee amount, if any, the  (5)  can charge.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: the

Fill-in (3) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's name

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: representative

ATY065 DETERMINATION OF REPRESENTATIVE'S ASSESSMENT AMOUNT – NH, NH AND AUXILIARIES OR AUXILIARIES ONLY – SSA PAYING TWO OR MORE REPRESENTATIVES SIMULTANEOUSLY, NO PREVIOUS ASSESSMENT (L35)

(Requested)

Caption: Information About Representative's Fees

We are paying the  (1)  from the benefits we withheld. Therefore, we must collect a service charge from each of them. The service charge is 6.3 percent of the fee amount we pay, but not more than $93, which is the most we can collect in each case under the law. When 6.3 percent of the combined payments exceeds $93, we divide the $93 service charge based on the individual fee amounts. We will subtract part of the service charge from the fee amount payable to each  (2)  .  (3) 

A  (4)  cannot ask  (5)  to pay for the service charge. If a  (6)  disagrees with the amount of the service charge, he or she must write to the address shown at the top of this letter. The  (7)  must tell us why he or she disagrees within 15 days from the day he or she gets this letter.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representatives

Fill-in (2) - Systems Generated

Choice 1: representative

Fill-in (3) - Requested As A One Position Alpha Character

Choice 1: (A) After we subtract the amount we are paying towards the fees, we will send you the balance of the amount we withheld.

Choice 2: (B) Null

Fill-in (4) - Systems Generated

Choice 1: representative

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (6) - Systems Generated

Choice 1: representative

Fill-in (7) - Systems Generated

Choice 1: representative

ATY066 DETERMINATION OF REPRESENTATIVE'S ASSESSMENT AMOUNT – NH, NH AND AUXILIARIES OR AUXILIARIES ONLY – SUBSEQUENT PAYMENT, SSA PREVIOUSLY ASSESSED LESS THAN $93 (L36)

(Requested)

Caption: Information About Representative's Fees

We are paying the  (1)  from the benefits we withheld. Therefore, we must collect a service charge from him or her. The service charge is 6.3 percent of the fee amount we pay, but not more than $93, which is the most we can collect in each case under the law. We previously paid a fee and collected  (2)  . The service charge we must collect now is  (3)  . We will subtract this service charge from the amount payable to the  (4)  .  (5)  The  (6)  cannot ask  (7)  to pay for the service charge. If the  (8)  disagrees with the amount of the service charge, he or she must write to the address shown at the top of this letter. The  (9)  must tell us why he or she disagrees within 15 days from the day he or she gets this letter.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative

Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢

Amount (assessment collected before)

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Amount (assessment being collected now)

Fill-in (4) - Systems Generated

Choice 1: representative

Fill-in (5) - Requested As A One Position Alpha Character

Choice 1: (A) After we subtract the amount we are paying towards the fee, we will send you the balance of the amount withheld.

Choice 2: (B) NULL

Fill-in (6) - Systems Generated

Choice 1: representative

Fill-in (7) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (8) - Systems Generated

Choice 1: representative

Fill-in (9) - Systems Generated

Choice 1: representative

ATY067 Appointed Representation Data and Fee Established Appointed Representation Data (L38)

(Requested)

Caption: Information About Representative's Fees

If a representative, who is a  (1)  , registers with us to receive direct fee payment, because of the law we usually withhold part of the past-due benefits to pay the fee we approve. Although  (2)  representative is a  (3)  , he or she did not register for direct payment before we completed our work on  (4)  claim. For that reason, we did not withhold from  (5)  past-due benefits to pay the fee we approve. Therefore, the Social Security Administration is not involved in paying the fee. This is a matter between  (6)  and  (7)   (8)  .

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1: (A) lawyer

Choice 2: (B) participant in the non-attorney direct payment demonstration project

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (3) - Systems Generated

Choice 1: lawyer

Choice 2: participant in the demonstration project

Fill-in (4) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (5) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (6) - Systems Generated

Choice 1: him

Choice 2 : her

Choice 3: you

Fill-in (7) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (8) - Systems Generated

Choice 1: representative

ATY068 REPRESENTATIVE FEE AGREEMENT – TITLE II/TITLE XVI – SSA WITHHOLDING PAST-DUE BENEFITS – NH (L14)

(Requested)

Caption: Information About Past-Due Benefits Withheld To Pay A Representative

 (1)  past-due Social Security benefits are  (2)  for  (3)  . Because of the law, we usually withhold 25 percent of the total past-due benefits or the maximum payable under the fee agreement to pay an approved  (4)  fee. We withheld  (5)  from  (6)  past-due benefits to pay the  (7)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: representative

Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢

Amount

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: representative

ATY069 FEE AGREEMENT AMOUNT – TITLE II/TITLE XVI – OFFSET INFORMATION PENDING (L15)

(Requested)

Caption: Information About Representative's Fees

Under the fee agreement, the  (1)  can charge  (2)  no more than  (3)  for his or her work on  (4)  Social Security claim. The amount of the fee does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between  (5)  and the  (6)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢ Amount

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: representative

ATY070 FEE AMOUNT – CONCURRENT TITLE II AND TITLE XVI CLAIMS – OFFSET INFORMATION PENDING – NH ONLY (L27)

(Requested)

Caption: Information About Representative's Fees

We base the amount of the  (1)  fee on the total past-due benefits for  (2)  and  (3)  family. Under the fee agreement, the  (4)  can charge  (5)   (6)  for his or her work. As soon as we make a decision on  (7)  family's claims and decide the amount of their past-due benefits, we will tell them if the  (8)  can charge an additional fee. We also will say how much that fee amount will be.

The amount of the fee for  (9)  and  (10)  family's claims does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between  (11)  and the  (12)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative's

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: representative

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (6) - Requested As A Money Amount In Format $$$$$.¢¢

Amount of the fee

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) - Systems Generated

Choice 1: representative

Fill-in (9) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (10) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (11) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (12) - Systems Generated

Choice 1: representative

ATY071 DETERMINATION OF REPRESENTATIVE'S ASSESSMENT AMOUNT – NH, NH AND AUXILIARIES OR AUXILIARIES ONLY – SSA PREVIOUSLY ASSESSED MAXIMUM (L37)

(Requested)

Caption: Information About Representative's Fees

We are paying the  (1)  from the benefits we withheld. We usually collect a service charge of 6.3 percent of the fee amount we pay, but not more than $93, which is the most we can collect in each case under the law. Because we paid a fee and collected the full amount before, there is no additional charge.  (2) 

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: (A) representative

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) After we subtract the amount we are paying towards the fee, we will send you the balance of the amount we withheld.

Choice 1: (B) NULL

ATY800 FEE AGREEMENT APPROVED NUMBER HOLDER (L01)

(Requested)

Caption: Information About Representative's Fees

We have approved the fee agreement between you and your  (1)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative

ATY801 FEE AGREEMENT APPROVED AUXILIARY (L02)

(Requested)

Caption: Information About Representative's Fees

When  (1)  filed  (2)  claim for benefits,  (3)  used a  (4)  to help with the claim. We have approved a fee agreement between  (5)  and  (6)   (7)  . The  (8)  work involved the benefits of everyone on the record.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Fill-in (3) - Systems Generated

Choice 1: he

Choice 2: she

Fill-in (4) - Systems Generated

Choice 1: representative

Fill-in (5) - Systems Generated

Choice 1: Beneficiary's Name

Fill-in (6) - Systems Generated

Choice 1: the

Fill-in (7): - Systems Generated

Choice 1: representative

Fill-in (8) - Systems Generated

Choice 1: representative's

ATY804 FEE AGREEMENT AMOUNT NUMBER HOLDER TITLE II CLAIM ONLY (L03)

(Requested)

Caption: Information About Representative's Fees

 (1)  past-due benefits are  (2)  for  (3)  . Under the fee agreement, the  (4)  cannot charge you more than  (5)  for his or her work. The amount of the fee does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and the  (6)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: Your

Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: past due benefits

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/CCYY and MM/CCYY

Choice 3: MM/CCYY through MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: representative

Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: pending fee amount

Fill-in (6) - Systems Generated

Choice 1: representative

ATY808 FEE REVIEW PROCEDURE NUMBER HOLDER (L06)

(Requested)

Caption: How To Ask Us To Review The Fee

You, the  (1)  or the person who decided your case can ask us to review the amount of the fee we say the  (2)  can charge.  (3) 

If you think the amount of the fee is too high, write us within 15 days from the day you get this letter. Tell us that you disagree with the amount of the fee and give your reasons. Send your request to this address:

Social Security Administration

Office of Disability Adjudication and Review

Attorney Fee Branch

5107 Leesburg Pike

Falls Church, Virginia 22041-3255

The  (4)  also has 15 days to write us if he or she thinks the amount of the fee is too low.  (5) 

If we do not hear from you or the  (6)  we will assume you both agree with the amount of the fee shown.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative

Fill-in (2) - Systems Generated

Choice 1: representative

Fill-in (3) - Requested As A One Position Alpha Character

Choice 1: (A) Your family members who have filed claims on your Social Security number (SSN) also may ask us to review the amount of the fee.

Choice 2: (B) null

Fill-in (4) - Systems Generated

Choice 1: representative

Fill-in (5) - Systems Generated

Choice 1: null

Choice 2: null

Fill-in (6) - Systems Generated

Choice 1: representative

ATY809 FEE REVIEW PROCEDURE AUXILIARY USED ONLY WHEN AUXILIARY PAID AT DIFFERENT TIMETHAN N/H OR LIVING IN SEPARATE HOUSEHOLD (L07)

(Requested)

Caption: How To Ask Us To Review The Fee

You,  (1)  , the  (2)  or the person who decided your case can ask us to review the amount of the fee we say the  (3)  can charge.

If you think the amount of the fee is too high, write us within 15 days from the day you get this letter. Tell us that you disagree with the amount of the fee and give your reasons. Send your request to this address:

Social Security Administration

Office of Disability Adjudication and Review

Attorney Fee Branch

5107 Leesburg Pike

Falls Church, Virginia 22041-3255

The  (4)  also has 15 days to write us if he or she thinks the amount of the fee is too low.  (5) 

If we do not hear from you or the  (6)  , we will assume you both agree with the amount of the fee shown.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: representative

Fill-in (3) - Systems Generated

Choice 1: representative

Fill-in (4) - Systems Generated

Choice 1: representative

Fill-in (5) - Systems Generated

Choice 1: null

Fill-in (6) - Systems Generated

Choice 1: representative

ATY816 NH FEE AGREEMENT DISAPPROVED NH REPRESENTED BY A REPRESENTATIVE. CAN ALSO BE USED WITH L14 OR L21 IN SSI/FEE PETITION CASE (L20)

(Requested)

Caption: Information About Representative's Fees

If your  (1)  wants us to pay the fee from your withheld benefits, he or she must ask us to approve the fee within 60 days of the date of this letter.

If your  (2)  :

  • Is finished working on this case and wants to charge a fee, he or she must tell us to approve the amount of the fee right away.

  • Is not finished working on this case and wants to charge a fee, he or she must tell us within 60 days of the date of this letter that he or she will ask for a fee.

  • Does not want to charge a fee or does not want us to pay the fee from the benefits we withheld, he or she should tell us right away.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative

Fill-in (2) - Systems Generated:

Choice 1: representative

ATY817 REVIEW OF THE DISAPPROVED FEE AGREEMENT – NH (L18)

(Requested)

Caption: How To Ask Us To Review The Determination On The Fee Agreement

You or the  (1)  can ask us to review the determination on the fee agreement. If you decide to ask us for a review, write us within 15 days from the day you get this letter. Tell us that you disagree and give your reasons. Send your request to this address:

Social Security Administration

Office of Disability Adjudication and Review

Attorney Fee Branch

5107 Leesburg Pike

Falls Church, Virginia 22041-3255

The  (2)  also has 15 days to write us if he or she does not agree with the determination on the fee agreement.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative

Fill-in (2) - Systems Generated

Choice 1: representative

ATY825 FEE AGREEMENT AMOUNT CONCURRENT TITLE II/TITLE XVI ADDITIONAL FEE FOR TITLE XVI CLAIM NUMBER HOLDER ONLY USE IN INITIALAWARDS/POSTENTITLEMENT/CESSATION CASES (L31)

(Requested)

Caption: Information About Representative's Fees

If we approve your claim for SSI, the  (1)  may be able to charge an additional amount for his or her work. We will send you another letter about SSI telling you the additional amount of the fee, if any, he or she can charge.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative

ATY834 FEE AGREEMENT AMOUNT NH AND AUXILIARIES TITLE II CLAIM ONLY (L04)

(Requested)

Caption: Information About Representative's Fees

 (1)  past-due benefits are  (2)  for  (3)  .  (4)  family's past-due benefits are  (5)  for  (6)  . Under the fee agreement, the  (7)  cannot charge  (8)  and  (9)  family more than  (10)  for his or her work. The amount of the fee does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and the  (11)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Full name possessive

Choice 2: Your

Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: money amount

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: Your

Choice 2: Her

Choice 3: His

Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: money amount

Fill-in (6) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (7) - Systems Generated

Choice 1: representative

Fill-in (8) - Systems Generated

Choice 1: Beneficiary's Name

Choice 2: you

Fill-in (9) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (10) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: pending fee amount

Fill-in (11) - Systems Generated

Choice 1: representative

ATY836 REPRESENTATIVE INVOLVED – SSA WITHHOLDING PAST DUE BENEFITS – NH (L09)

(Requested)

Caption: Information About Past-Due Benefits Withheld To Pay A Lawyer

Based on the law, we must withhold part of past-due benefits to pay an appointed representative. We cannot withhold more than 25 percent of past-due benefits to pay an authorized fee. We withheld  (1)  from  (2)  past-due benefits to pay  (3)  representative.

Fill-in values:

Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount

Fill-in (2) - Systems Generated

Choice 1: Mr. Beneficiary's Name possessive

Choice 2: Ms. Beneficiary's Name possessive

Choice 3: Beneficiary's First Name possessive

Choice 4: Beneficiary's Name possessive

Choice 5: your

Fill-in (3) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Choice 4: Beneficiary's Name possessive

Choice 5: the

ATY838 REPRESENTATIVE FEE AGREEMENT – TITLE II/TITLE XVI SSA WITHHOLDING PAST DUE BENEFITS – N/H AND AUXILIARIES (L21)

(Requested)

Caption: Information About Past-Due Benefits Withheld To Pay A Lawyer

Because of the law, we usually withhold 25 percent of the total past-due benefits to pay an approved  (1)  fee.

We withheld  (2)  from  (3)  past-due benefits to pay  (4)   (5)  . We also withheld  (6)  from  (7)  family's past-due benefits. We base the amount of the fee  (8)   (9)  can charge on the total past-due benefits due  (10)  and  (11)  family.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative's

Fill-in (2) - Systems Generated

Representative Fee Amount

Fill-in (3) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (4) - Systems Generated

Choice 1: the

Fill-in (5) - Systems Generated

Choice 1: representative

Fill-in (6) - Systems Generated

Choice 1: Amount

Fill-in (7) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (8) - Systems Generated

Choice 1: the

Fill-in (9) - Systems Generated

Choice 1: representative

Fill-in (10) - Systems Generated

Choice 1: Beneficiary Name

Choice 2: you

Fill-in (11) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

ATYR02 FEE AMOUNT UNKNOWN-NH PAST-DUE BENEFITS UNKNOWN OR AUXILIARY (IES) CLAIM PENDING (L08)

(Requested)

Caption: Information About Representative's Fees

We base the amount of  (1)  fee on past-due benefits, if any. As soon as we  (2)  determine the amount of past-due benefits, we will tell you the amount of the fee  (3)  can charge.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your representative's

Choice 2: the representative's

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) make a decision on your spouse's claim and

Choice 2: (B) make a decision on your family's claims and

Choice 3: (C) make a decision on your child's claim and

Choice 4: (D) make a decision on your children's claim and

Choice 5: (E) Null

Fill-in (3) - Systems Generated

Choice 1: your representative

Choice 2: the representative

ATYR03 FEE AGREEMENT SUBSEQUENTLY DISAPPROVED – NO PAST DUE BENEFITS – NH – TITLE II ONLY (L29)

(Requested)

Caption Information About Representative's Fees

We wrote you before and said we had approved the fee agreement between  (1)  and the  (2)  . We also said we would tell  (3)  and the  (4)  the amount of the fee he or she can charge  (5)  .

We base the fee amount we allow under a fee agreement on  (6)  past-due benefits. There are no past-due benefits. Therefore, we no longer approve the fee agreement between  (7)  and the  (8)  .

Even though we no longer approve the fee agreement, the  (9)  can still charge a fee for his or her services. If the  (10)  wants to charge a fee, he or she must ask us in writing to approve the fee. The  (11)  must give  (12)  a copy of his or her fee request and each attachment to the request. If the  (13)  does not want to charge a fee, he or she should tell us.

Fill-in values:

Fill-in (1) - Requested As A Language

Choice 1: Name of Beneficiary who hired the attorney or representative

Fill-in (2) - Systems Generated

Choice 1: representative

Fill-in (3 - Systems Generated

Choice 1: Ms. + Beneficiary's Last Name

Choice 2: Mr. + Beneficiary's Last Name

Choice 3: Beneficiary's First Name

Choice 4: Beneficiary's Name

Choice 5: you

Fill-in (4 - Systems Generated

Choice 1: representative

Fill-in (5 - Systems Generated

Choice 1: Ms. + Beneficiary's Last Name

Choice 2: Mr. + Beneficiary's Last Name

Choice 3: Beneficiary's First Name

Choice 4: Beneficiary's Name

Choice 5: you

Fill-in (6) - Systems Generated

Choice 1: her

Choice 2: his

Choice 3: your

Fill-in (7) - Systems Generated

Choice 1: her

Choice 2: him

Choice 3: you

Fill-in (8) - Systems Generated

Choice 1: representative

Fill-in (9) - Systems Generated

Choice 1: representative

Fill-in (10) - Systems Generated

Choice 1: representative

Fill-in (11) - Systems Generated

Choice 1: representative

Fill-in (12) - Systems Generated

Choice 1: her

Choice 2: him

Choice 3: you

Fill-in (13) - Systems Generated

Choice 1: representative

ATYR05 FEE AGREEMENT AMOUNT AUXILIARY TITLE II CLAIM ONLY -USED ONLY WHEN AUXILIARY PAID AT DIFFERENT TIME THAN N/H OR LIVING IN SEPARATE HOUSEHOLD (L16)

(Requested)

Caption: Information About Representative's Fees

 (1)  past-due benefits are  (2)  for  (3)  . Under the fee agreement between  (4)  and the  (5)  , the  (6)  cannot charge more than  (7)  for his or her work.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Full name possessive

Fill-in (2) - Systems Generated

Choice 1: amount

Fill-in (3) - Systems Generated

Choice 1: month and year

Choice 2: month and year through month and year

Fill-in (4) - Requested As A Language

Choice 1: Beneficiary's Name

Fill-in (5) - Systems Generated

Choice 1: representative

Fill-in (6) - Systems Generated

Choice 1: representative

Fill-in (7) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: money amount

ATYR12 REPRESENTATIVE INVOLVED – SSA WITHHOLDING PAST-DUE BENEFITS – AUXILIARY (IES) (L11)

(Requested)

Caption: Information About Past-Due Benefits Withheld To Pay A Representative

Because of the law, we usually withhold 25 percent of the total past-due benefits to pay an approved  (1)  fee. We withheld  (2)  from  (3)  past-due benefits to pay  (4)   (5)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative's

Fill-in (2) - Systems Generated

Choice 1: (Amount)

Fill-in (3) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (4) - Systems Generated

Choice 1: the

Fill-in (5) - Systems Generated

Choice 1: representative

ATYR15 FEE AGREEMENT NOT APPROVED – NH (L19)

(Requested)

Caption: Information About Representative's Fees

We cannot approve the fee agreement between you and your  (1)  because  (2) 

Even though we cannot approve the fee agreement, your  (3)  can still charge you a fee for his or her services. If your  (4)  wants to charge a fee, he or she must ask us in writing to approve the amount of the fee. Your  (5)  must give you a copy of his or her fee request and each attachment to the request. If your  (6)  does not want to charge a fee, he or she should tell us.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) we did not get a written agreement before we decided your claim.

Choice 2: (B) both you and your (representative) did not sign the agreement.

Choice 3: (C) it sets a fee amount that is more than 25 percent of past- due benefits or $6000.00.

Choice 4: (D) there are no past-due benefits. We base the fee amount we allow under a fee agreement on your past-due benefits. Since we do not owe you any past-due benefits, we cannot approve the fee agreement.

Choice 5: (E) you appointed more than one representative from a law firm or other business, and all representatives did not sign a single fee agreement (unless the representative(s) who did not sign waived any fee in your case).

Choice 6: (F) you appointed representatives who are not members of the same law firm or other business (unless the representative(s) from the other law firm or business waived any fee in your case).

Choice 7: (G) you discharged a representative, or a representative withdrew from the case, before we favorably decided the claim (unless the former representative waived any fee in your case).

Choice 8: (H) your representative died before we issued the favorable decision.

Choice 9: (I) you were declared legally incompetent by a State court and your guardian did not sign the fee agreement.

Fill-in (3) - Systems Generated

Choice 1: representative

Fill-in (4) - Systems Generated

Choice 1: representative

Fill-in (5) - Systems Generated

Choice 1: representative

Fill-in (6) - Systems Generated

Choice 1: representative

ATYR20 FEE AMOUNT – TITLE II CLAIM ONLY – NH ONLY – DELAYED AUXILIARY CLAIM(S) PENDING OR EXPECTED – NH'S AWARD NOTICE (L25)

(Requested)

Caption: Information About Representative's Fees

We base the amount of the  (1)  fee on the total past-due benefits for you and your family. Your past-due benefits are  (2)  for  (3)  . Under the fee agreement, the  (4)  can charge you  (5)  for his or her work. As soon as we make a decision on your family's claim(s) and decide the amount of their past-due benefits, we will tell them if the  (6)  can charge an additional fee. We also will say how much that fee amount will be.

The amount of the fee for your and your family's claim(s) does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and the  (7)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative's

Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: PDB

Choice 2: PMA

Fill-in (3) - Systems Generated

Choice 1: DOEC in the format Month CCYY

Choice 2: DOES through LAST-WITHHOLDING-DATE in the format Month CCYY and Month CCYY

Choice 3: the period from DOEC through LAST-WITHHOLDING- DATE in the format Month CCYY through Month CCYY

Fill-in (4) - Systems Generated

Choice 1: representative

Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Pending-Fee-Agreement-Amount

Fill-in (6) - Systems Generated

Choice 1: representative

Fill-in (7) - Systems Generated

Choice 1: representative

ATYR22 FEE AMOUNT – CONCURRENT TITLE II AND TITLE XVI CLAIMS – OFFSET INFORMATION PENDING – NH AND NON-DELAYED AUXILIARY BENEFICIARY(IES) – DELAYED AUXILIARY CLAIMS PENDING OR EXPECTED – NH'S AWARD NOTICE(L26)

(Requested)

Caption: Information About Representative's Fees

We base the amount of the  (1)  fee on the total past-due benefits for you and your family. Your past-due benefits are  (2)  for  (3)  .  (4)  past-due benefits are  (5)  for  (6)  . Under the fee agreement, the  (7)  can charge you and  (8)   (9)  for his or her work. As soon as we make a decision on your  (10)  and decide the amount of the past-due benefits, we will tell  (11)  if the  (12)  can charge an additional fee. We also will say how much that fee amount will be.

The amount of the fee for your and your family's claim(s) does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and the  (13)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: representative's

Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: sum of number holder's PMA and LPDA

Choice 2: number holder's PMA

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: DOEC in the format MONTH CCYY

Choice 2: DOEC through LAST-WITHHOLDING-DATE in the format MONTH CCYY and MONTH CCYY

Choice 3: the period from DOEC through LAST_WITHHOLDING- DATE in the format MONTH CCYY through MONTH CCYY

Fill-in (4) - Requested As A One Position Alpha Character

Choice 1: (A) Beneficiary's Name, possessive

Choice 2: (B) Your family's

Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Money Amount

Fill-in (6) - Systems Generated

Choice 1: DOEC in the format MONTH CCYY

Choice 2: DOEC through LAST-WITHHOLDING-DATE in the format MONTH CCYY and MONTH CCYY

Choice 3: the period from DOEC through LAST-WITHHOLDING- DATE in the format MONTH CCYY through MONTH CCYY

Fill-in (7) - Systems Generated

Choice 1: representative

Fill-in (8) - Systems Generated

Choice 1: Beneficiary's Name, possessive

Choice 2: your family

Fill-in (9) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Money Amount

Fill-in (10) - Requested As A One Position Alpha Character

Choice 1: (A) spouse's claim

Choice 2: (B) other child's claim

Choice 3: (C) other children's claims

Choice 4: (D) spouse's and other child's claims

Choice 5: (E) spouse's and other children's claims

Fill-in (11) - Systems Generated

Choice 1: him

Choice 2: her

Choice 3: them

Fill-in (12) - Systems Generated

Choice 1: representative

Fill-in (13) - Systems Generated

Choice 1: representative


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900720050
NL 00720.050 - ATY Representative Fee - 11/15/2017
Batch run: 11/15/2017
Rev:11/15/2017