We have withheld $____, which represents 25 percent of the past-due benefits payable to _____, as required by sections 206(a) and (b) and/or 1631(d) of the Social Security Act. We have withheld this amount since ______. We previously notified you that you should submit a request for a fee for services before the court to the United States District Court for the ___ District of ______. [You should submit any petition for a fee for services before the Administration to the Attorney Fee Officer in the Office of Disability Adjudication and Review.]
We do not wish to delay the release of funds withheld from the claimant’s past-due benefits. Therefore, pursuant to section 404.1730(c) of Social Security Administration (SSA) Regulations No. 4 (20 CFR 404.1730(c)), we will certify for payment to the claimant all withheld benefits unless you file a petition for approval of a fee within 20 days from the date of this letter, or a written request for an extension of time. If you request an extension of time, send a copy of your request to your client.
Any fee you may wish to charge hereafter for your services on this claim will still be subject to court or SSA approval. Failure to comply with this requirement could result in a violation of section 206 and/or 1631of the Act (42 U.S.C. 406 and 1383). Collection of any such approved fee shall be a matter between you and your client.
Please forward your petition for a court fee to the U.S. District Court. [If you request a separate administrative fee, send the fee petition to: Social Security Administration
Office of Appellate Operations
5107 Leesburg Pike
Falls Church, VA 22041-3255
If you are waiving your fee, please forward a statement, signed and dated by you, that you will not charge a fee. Send the statement to:
Social Security Administration
The fax number is ____________. Please fax any statements or questions about this notice to us at that number.
We are sending a copy of this letter to your client.
If the attorney does not submit a petition for the court fee within 60 days, check all sources to ensure that there has been no fee activity. If there has been none, release the withheld benefits to the claimant(s).
If the attorney has petitioned the court, refer to GN 03930.091C.1.
If the attorney indicates that he/she will waive the fee, refer to GN 03930.091C.3.