Identification Number:
GN 03905 TN BASIC
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Forms, Exhibits and Notices for Representatives
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part GN – General
Chapter 039 – Representation and Representative's Fee
Subchapter 05 – Forms, Exhibits and Notices for Representatives
Transmittal No. BASIC, 12/10/2019

Audience

PSC: BA, CA, DS, ICDS, IES, ILPDS, IPDS, ISRA, PETE, RECONR, SCPS;
OCO-OEIO: BIES, BTE, CIES, CR, CTE, PETL, RECONR, RECOVR;
OCO-ODO: BTE, CR, CST, CTE, CTE TE, DS, PETE, PETL, RCOVTA, RECOVR;
FO/TSC: CS, CS TII, CS TXVI, CSR, CTE, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

ODP

Effective Date

Upon Receipt

Background

We consolidated all forms, notices and exhibits to simplify user searches into this new subchapter and organized the material for a logical presentation: registration, appointment, payment fee agreement and fee petition. We also added exhibits of Registration and Appointment Services for Representatives (RASR) notices and links to new forms. With the publication of this POMS chapter, we can archive sections GN 03910.090, GN 03930.140, GN 03930.145, GN 03930.150, GN 03930.155, GN 03930.160, GN 3930.170 and GN 03940.090.

We added the “When to use” introduction to every section to describe the usage of the form.

 

Summary of Changes

GN 03905.001 Overview of Forms, Exhibits and Notices

This section provides an overview of the new subchapter on forms, exhibits, and notices used in the registration, appointment, and fee process for representatives and claimants.

GN 03905.005 Representation Referral List Model Notice

This notice exhibit was previously located in GN 03910.090, exhibit 1.

GN 03905.010 Form SSA-1699 Registration for Appointed Representative Services and Direct Payment

The link to this form was previously located in GN 03910.090, exhibit 7.

GN 03905.015 Form SSA-1694 Request for Business Entity Taxpayer Information

The link to this form was previously located in GN 03910.090, exhibit 5.

GN 03905.020 Registration, Appointment, and Services for Representatives (RASR) Registration Notices

We are exhibiting RASR registration notices RSR101 and RSR102 in this section. These notices can be automatically released through RASR once we completed our actions.

GN 03905.025 Form SSA-1128 Representative Involved

The link to this form was previously located in GN 03910.090, exhibit 4.

GN 03905.030 Forms SSA-1696 Appointment, Revocation, and Withdrawal

The link to the form SSA-1696 Appointment of Representative was previously located in GN 03910.090, exhibit 2. We revised and renamed form SSA-1696 Claimant's Appointment of a Representative. The revised form includes the affiliation information (EIN) from the SSA-1695. (Form SSA-1695 will be archived with the publication of the revised SSA-1696. Form SSA-1695 was located in GN 03910.090, exhibit 6)

We are inserting links to the new SSA-1696-SUP1 Claimant's Revocation of the Appointment of a Representative and SSA-1696-SUP2 Representative's Withdrawal of Acceptance of an Appointment.

GN 03905.035 Registration, Appointment, and Services for Representatives (RASR) Appointment, Revocation, and Withdrawal Notices

These RASR notices replace form SSA-L1967-U3 Notice to Representative of Claimant Before the Social Security Administration, previously located in GN 03910.090, exhibit 3. The notices can be released automatically through RASR once we completed our actions. The exhibit includes RASR notices RSR103, RSR104, RSR106, RSR107, and RSR108.

GN 03905.040 Form SSA-1129 Attorney Fee Case Past-due Benefits Summary

This form was previously linked in GN 03920.065. We are adding a link here to complete the exhibit of all forms available for the appointed representative policy.

GN 03905.050 Registration, Appointment, and Services for Representatives (RASR) Direct Payment Notice

The RASR notice RSR105 replaces GN 03910.090, exhibit 9, Preprinted Notice (SSA-1695 Acknowledgment of Receipt and Input).

GN 03905.055 Invalid Appointment Forms

We replaced GN 03910.090, exhibit 8 (Preprinted Notice (Return of Form SSA-1695 and SSA-1699) with DPS notice REP028 (Appointment not recognized - no pending matter).

GN 03905.060 Form SSA-1693 Fee Agreement for Representation Before SSA

This form was previously not linked in our POMS. This is a new form published in December 2018. Thus the model fee agreement language in GN 03940.090, exhibit 1 is unnecessary.

GN 03905.065 Fee Authorization Notice Exhibits Under the Fee Agreement Process

These exhibits were previously listed in GN 03940.090, exhibits 2 - 6.

GN 03905.070 Form SSA-1560 Petition to Obtain Approval of a Fee for Representing a Claimant

The link to this form was previously located in GN 03930.155.

GN 03905.075 Fee Petition Processing Notices

These exhibit notices were previously listed in GN 03930.014 and GN 03930.145.

GN 03905.080 Form SSA-1178 Evaluation of Fee Petition for Representation

The link to this form was previously located in GN 03930.150.

GN 03905.085 Form SSA-1560A Authorization to Charge and Collect a Fee

The link to this form was previously in GN 03930.160.

GN 03905.090 Direct Payment to Representative from TXVI Past-Due Benefits Model Fee Notice

This exhibit notice was previously listed in GN 03930.170.

Conversion Table
Old POMS ReferenceNew POMS Reference
GN 03910.090GN 03905.005
GN 03910.090GN 03905.015
GN 03910.090GN 03905.025
GN 03910.090GN 03905.030
GN 03910.090GN 03905.035
GN 03910.090GN 03905.045
GN 03920.065GN 03905.050
GN 03910.090GN 03905.055
GN 03940.090GN 03905.060
GN 03940.090GN 03905.065
GN 03930.155GN 03905.070
GN 03930.140GN 03905.075
GN 03930.145GN 03905.075
GN 03930.150GN 03905.080
GN 03930.160GN 03905.085
GN 03930.170GN 03905.090

GN 03905.001 Overview of Forms, Exhibits, and Notices

Subchapter GN 03905 contains the forms, exhibits, and notices we use to communicate with representatives and claimants.

Other notices used to communicate with representatives :

Notices used in the administrative review of fee authorizations under the fee petition process are in GN 03950.000 .

Notices used in the administrative review of determinations under the fee agreement process are in GN 03960.000 .

Notices used in the suspension or disqualification process for representatives suspected or charged with violating our rules are in GN 03970.000 .

GN 03905.005 Representation Referral List Model Notice

A. When to use

We maintain a representational referral list for each field office and hearing office service area. We provide this list to all claimants who receive an adverse determination or decision during the administrative review process. The information we provide to claimants is neutral and the organizations use their own criteria to determine whether the claimant qualifies for any free services. For more information, see GN 03910.030.

B. Sample notice

IMPORTANT NOTICE

IF YOU WANT TO OBTAIN A PRIVATE ATTORNEY to represent you and you need assistance in obtaining an attorney's services, you may contact one of the organizations shown below. They can refer you to a private attorney who is familiar with representing claimants before the Social Security Administration. Some private attorneys may be willing to take your case under an arrangement in which he or she will not charge a fee unless your claim is allowed. The attorney must obtain the Social Security Administration's authorization for any fee he or she wants to charge and collect.

These organizations have indicated that they want to be included on this list. The Social Security Administration has made no attempt to evaluate their services.

 

NAME AND ADDRESS SERVICES

Lawyers Referral Services 629 Municipal Courts Building 111 N. Wilson Street Anytown, USA

Phone: 123-4561

Lawyers Referral Services 825 South Courthouse Square Anyville, USA

Phone: 123-4567

Serves claimants residing in Anytown.

Serves claimants residing in Anyplace County.

IF YOU ARE NOT ABLE TO PAY FOR REPRESENTATION and you believe you might qualify for free legal representation, you should contact one of the following organizations:

NAME AND ADDRESS SERVICES

Anyplace County Legal Services Organization 815 Wilmington Avenue Anyplace, USA

Phone: 123-4563

Serves claimants residing in Anyplace County.

COMMUNITY ORGANIZATIONS that may provide you with non-attorney representation are:

Veterans of Foreign Wars 100 Veterans Avenue Anyplace, USA

Phone: 123-4564

Provides paralegals and other non-attorney representatives for qualifying veterans who reside in the metropolitan Anyplace area.

Disabled American Veterans 100 Downtown Boulevard Anyville, USA

Phone: 123-4565

Provides paralegals and other non-attorney representatives for disabled American veterans residing in the metropolitan Anyville area.

Any State University Community Legal Clinic 100 University Boulevard Anyville, USA

Phone: 123-4566

Provides paralegals and other non-attorney representatives for claimants living in southwestern Any State.

Anytown University College of Law 100 College Avenue Anytown, USA

Phone: 123-4567

Provides paralegals and other non-attorney representatives for claimants living in greater Anytown.

GN 03905.010 Form SSA-1699 Registration for Appointed Representative Services and Direct Payment

A. When to use

Representatives use Form SSA-1699 to register with us for direct payment, to provide information required for Internal Revenue Service income tax reporting, and to obtain e-folder access. For more information on the registration process, see

  • GN 03913.025 Paper Registration (Form SSA-1699) - Individual

  • GN 03913.030 Paper Registration (Form SSA-1699) - Field office Process

B. Exhibit

Click here to obtain the most current Form SSA-1699 in PDF format.

GN 03905.015 Form SSA-1694 Request for Business Entity Taxpayer Information

A. When to use

We must file a Form 1099-MISC with the Internal Revenue Services when we pay $600 or more per year to an appointed representative for representative services. When the representative informs us of his or her association with a business entity as an employee or partner, we use Form SSA-1694 to obtain the name, address, and employer identification number of the business entity. We must enter the information from the SSA-1694 into the Registration, Appointment and Services for Representatives (RASR) system. For more information on the form and the registration process see GN 03925.001.

B. Exhibit

See Form SSA-1964 for the most current PDF.

 

GN 03905.020 Registration, Appointment and Services for Representatives (RASR) Registration Notices

A. When to use

We use RASR system to register representatives. Once we complete the registration by entering the information of Forms SSA-1699 and SSA-1694, RASR automatically releases notices to appointed representatives and their claimants. This section contains RASR sample notices related to registration.

B. Exhibits

1. RSR101 - Registration confirmation

Thank you for submitting your information to register with us. Your registration is now complete.

We have assigned you two access identifications: a USER ID and a REP ID. You will need your REP ID to do business with us as an appointed representative. Your USER ID is for access to the Social Security Administration's online services. Please keep this information in a safe place.

USER ID: AABB0007

REPID: RCC1RSXLXL

If you have not created a password in our Business Services Online (BSO) portal, please visit www.socialsecurity.gov/ar to create one. On the informational page titled "Appointed Representative Services", select "Click this link to go to the login page" under "Current ARS Users" to create a password.

The password you choose during the registration process is valid for 90 days. You must change your password during the login process if your password is older than 90 days. Your password may contain any combination of eight letters and numbers. No special characters are allowed (e.g., # or &).

Do not share your User ID or leave it where others can access it. Go to www.socialsecurity.gov/ar to change your password if it is compromised.

Suspect Social Security Fraud?

If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

Please visit our Representing Claimants website at www.socialsecurity.gov/representation for general information.

If you have questions, please call us at 1-800-772-6270. If you are hearing impaired, you may call the TTY number, 1-800-325-0778 between 7:00 a.m. and 7:00 p.m. Eastern Standard time, Monday through Friday. We can answer most of your questions over the phone. When you call, please have this letter with you to help us answer your questions.

2. RSR102 - Registration update

Thank you for updating your user information.

We are writing to inform you that we have made the following changes to your record:

Section I: Your Personal Identification and Home Contact Information

Choices:

  • We changed your Contact Name. NOTE: We use your name exactly as it appears

on your Social Security card. If you want to use a different name, contact your local Social Security office to change the name currently in our records.

  • You must either receive a new card or receive confirmation that we processed

your name change prior to completing another SSA-1699 form to update your Contact Name.

  • You requested that we change your Home Mailing Address.

  • You requested that we change your Telephone Number, Fax Number, or Email

Address.

Section III: Your Bar and Court Information

You requested that we change your Court or Bar Name, Status, Year Admitted or License Number.

Section IV: Your Information as a Representative

Choices:

  • You requested that we change your Address for Receipt of Notices. If you are currently

eligible for Direct Payment of fees and receive your payment in the form of a paper check, your paper check will be mailed to this address.

  • You requested that we change your Business Telephone Number, Business Fax Number, or Business Email Address.

  • You are eligible for Direct Payment of fees. If you have not provided your preferred payment method, you will receive payment in the form of a paper check.

  • Your paper check will be mailed to your Address for Receipt of Notices.

  • You requested that we change your preferred payment method to check. Your paper

check will be mailed to your Address for Receipt of Notices.

  • You requested we change your financial account information.

  • You requested that we change your preferred payment method to Direct Deposit.

  • You requested that we change your Tax Address. This is the address where we

will send your Form "1099-MISC."

  • You are no longer eligible for Direct Payment.

Section V: Your Information When You Are Working for a Firm or Organization

Choices:

  • You requested that we add, change, or end a Firm(s) or Organization(s) that you will be affiliated with as a representative.

  • You requested that we change your Address for Receipt of Notices when you are working for a Firm or Organization.

  • You requested that we change your Business Telephone Number, Business Fax Number,

or Business Email Address when you are working for a Firm or Organization.

  • You requested that we change your preferred payment method to check when you are working for a Firm or Organization. Your paper check will be mailed to your Address for Receipt of Notices.

  • You requested we change your financial account information when you are working

for a Firm or Organization.

  • You requested that we change your preferred payment method to Direct Deposit when you are working for a Firm or Organization.

Section VI: Attestation and Questions for Representation

You requested that we add information to your record related to your representational status.

Suspect Social Security Fraud?

If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

Please visit our Representing Claimants website at www.socialsecurity.gov/representation for general information.

If you have questions, please call us at 1-800-772-6270. If you are deaf or hard of hearing, you may call the TTY number, 1-800-325-0778 between 7:00 a.m. and 7:00 p.m. Eastern time, Monday through Friday. We can answer most of your questions over the phone. When you call, please have this letter with you to help us answer your questions.

If you have questions about reporting income or Form 1099-MISC, please contact the Internal Revenue Service.

GN 03905.025 Form SSA-1128 Representative Involved

A. When to use

We use this form to flag paper folders when an appointed representative is involved.

B. Exhibit

See form SSA-1128 for the most current PDF.

GN 03905.030 Forms SSA-1696 Appointment, Revocation, and Withdrawal

A. When to use

A claimant must notify us in writing (e.g., Form SSA-1696 or "equivalent writing") if he or she appoints an individual to represent him or her in dealings with us. A claimant must also let us know in writing when he or she wants to revoke a representative's appointment. Likewise, an appointed representative must notify us in writing when he or she wants to withdraw from an appointment. Claimants and representatives have the options to use our forms for their actions.

B. Exhibits

1. Form SSA-1696 Claimant's Appointment of a Representative

See Form SSA-1696 to obtain the most current PDF.

2. Form SSA-1696-SUP1 Claimant's Revocation of the Appointment of a Representative

See Form SSA-1696-SUP1 to obtain the most current PDF.

3. Form SSA-1696-SUP2 Representative's Withdrawal of acceptance of an Appointment

See Form SSA-1969-SUP2 to obtain the most current PDF.

GN 03905.035 Registration, Appointment, and Services for Representatives (RASR) Appointment, Revocation, and Withdrawal Notices

A. When to use

The claimant and the representative must submit a notice of appointment (e.g., Form SSA-1696 or "equivalent writing") for the appointment of a representative to take effect. Once we complete entering the information into RASR, the system automates the release of notices to appointed representatives and their claimants. This section contains the notices related to appointment, withdrawal, and revocation of a representative.

B. Exhibits

1. RSR 103 - Appointment confirmation to appointed representative

We received written notice that [claimant name] has appointed you to act as his or her representative for his or her claim(s). Therefore, we will deal directly with you on matters that concern this claim(s).

We have processed the Form SSA-1695 “Identifying Information for Possible Direct Payment of Authorized Fees” that you submitted for [claimant name].

We have processed your updated direct payment information for the representation of [claimant name].

We have recorded [firm name] with the EIN […] as your affiliation for this claim.

If you plan to charge a fee for services, you must file either a fee petition or a fee agreement with us. In either case, you cannot charge more than the fee amount we authorize you.

Fee Agreement Process

You must submit your fee agreement to us before we make the first favorable decision on the matter on which you worked. We will approve your agreement if it meets certain requirements. We will consider the fee agreement only if we favorably decide the claimant’s case and our decision results in past-due benefits. Find more information about fee agreements on our website at www.ssa.gov/representation/fee_agreements.htm.

OR

Fee Petition Process

You must submit your fee petition to us after your services end, even if the matter you worked on is still pending decision. For convenience, you may use Form SSA-1560, available on our website at www.ssa.gov/online/ssa-1560.html or through your local Social Security office. If you are eligible for and seek direct payment, note that there are important deadlines for submitting a fee petition so that we withhold funds to pay the fee directly to you. Find more information about fee petitions on our website at www.ssa.gov/representation/fee_petitions.htm.

We withhold up to 25 percent of the claimant’s past-due benefits. We will pay the authorized fee after deducting the assessment as required by the Social Security Act. You cannot charge or collect this expense from the claimant. When the fee exceeds the withheld amount or the representative is not eligible for direct payment, the representative must seek payment from the claimant.

If You Waive Your Fee

If you choose to waive either a fee or direct payment of a fee, you can do so by updating your fee arrangement on the notice of appointment.

Early filing of the waiver enables us to prevent withholding of past-due benefits for direct payment.

Important Note: After your appointment ends, you will no longer have access to the claimant’s records or personal information.

Suspect Social Security Fraud?

If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the

Inspector General’s Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

Please visit our Representing Claimants website at www.socialsecurity.gov/representation for general information.

If you have questions, please call us at 1-800-772-6270. If you are deaf or hard of hearing, you may call the TTY number, 1-800-325-0778 between 7:00 a.m. and 7:00 p.m. Eastern time, Monday through Friday. We can answer most of your questions over the phone. When you call, please have this letter with you to help us answer your questions.

If you have questions about reporting income or Form 1099-MISC, please contact the Internal Revenue Service.

2. RSR104 - Appointment confirmation to claimant

We received written notice that you appointed [representative’s name] to represent you for your claim(s). Therefore, we will deal directly with [representative’s name] on matters that concern your claim(s), unless you tell us otherwise.

Suspect Social Security Fraud?

If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

For general information about Social Security, we invite you to visit our website at www.socialsecurity.gov on the Internet. For general questions and specific questions about your case, you may call us toll-free at 1-800-772-1213. You can also call your local Social Security office at 888-329-5721. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number 1-800-325-0778. If you do call or visit an office, please have this letter with you. It will help us answer your questions.

3. RSR106 - Appointment revocation to appointed representative

[Claimant’s name] asked us to revoke your appointment on [date]. We no longer recognize you as the appointed representative for [claimant’s name].

Important Note: After your appointment ends, you will no longer have access to the claimant's records or personal information.

What Happens Next

With limited exceptions, if you plan to charge a fee for your services, you must file a fee petition with us and may not charge more than the fee amount we approve. Any fee petition should be submitted in the next 20 days. We will make a decision on your fee petition after we make a final decision on the claim. To find out how to file a fee petition visit www.ssa.gov/representation/fee_petitions.htm

If You Waive Your Fee

If you wish to waive a fee, you can do so by returning the attachment below within the next 20 days.

Suspect Social Security Fraud?

If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

Please visit our Representing Claimants website at www.socialsecurity.gov/representation for general information.

If you have questions, please call us at 1-800-772-6270. If you are hearing impaired, you may call the TTY number, 1-800-325-0778 between 7:00 a.m. and 7:00 p.m. Eastern Standard time, Monday through Friday. We can answer most of your questions over the phone. When you call, please have this letter with you to help us answer your questions.

4. RSR107 - Appointment withdrawal to claimant

We no longer recognize [representative’s name] as your representative, because we received a withdrawal request on [date]. This change will not affect how we decide your claim(s) or any other matter that you have before us.

What Happens Next

You may choose to appoint someone else to represent you. Until you decide whether to appoint another representative, we will deal directly with you. We will help you with your claim(s).

[representative’s name] may ask for a fee for services up to the withdrawal date. If the representative who has withdrawn asks for a fee from you, we will let you review the request before we decide the fee amount. The representative may collect the fee directly from you.

Suspect Social Security Fraud?

If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

For general information about Social Security, we invite you to visit our website at www.socialsecurity.gov on the Internet. For general questions and specific questions about your case, you may call us toll-free at 1-800-772-1213. You can also call your local Social Security office at 866-708-3210. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number 1-800-325-0778. If you do call or visit an office, please have this letter with you. It will help us answer your questions.

5. RSR108 - Appointment withdrawal to claimant - replacement principal

We no longer recognize [representative’s name] as your representative, because we received a withdrawal request on December 5, 2017. This change will not affect how we decide your claim(s) or any other matter that you have before us.

What Happens Next

You have appointed other representatives on your claim(s). We have selected [representative’s name] to be your principal representative. However, you may choose to select one of your other representatives to be your principal representative. Until you decide, we will deal directly with [representative’s name].

[Representative’s name] may ask for a fee for his or her services through [date]. If the representative who has withdrawn asks for a fee, we will let you review the request before we decide the fee amount. The representative may collect the approved fee directly from you.

Suspect Social Security Fraud?

If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

For general information about Social Security, we invite you to visit our website at www.socialsecurity.gov on the Internet. For general questions and specific questions about your case, you may call us toll-free at 1-800-772-1213. You can also call your local Social Security office at 866-708-3210. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number 1-800-325-0778. If you do call or visit an office, please have this letter with you. It will help us answer your questions.

GN 03905.040 Form SSA-1129 Representative Fee Case Past-due Benefits Summary

A. When to use

We use this form to manually calculate the past-due benefits and the resulting representative’s fee. See GN 03920.045 for more information.

B. Exhibit

See Form SSA-1129 for the most current PDF. (Link not available at this time.)

 

GN 03905.050 Registration, Appointment and Services for Representatives (RASR) Direct Payment Change Notice

A. When to use

When representatives request a change for the direct payment designation, we must process the amended submission. Once we complete entering the change in the representative's affiliation information into RASR, the system automatically releases notices to appointed representatives and their claimants. This section contains the notice related to a change in a representative's direct payment information.

B. Exhibits

1. RSR105 - Direct Payment Change Request Received

We have processed a change in your information for direct payment you submitted for [claimant’s name].

We have recorded [firm’s name] with the EIN […] as your affiliation for this claim.

Suspect Social Security Fraud?

If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the

Inspector General’s Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

Please visit our Representing Claimants website at www.socialsecurity.gov/representation for general information.

If you have questions, please call us at 1-800-772-6270. If you are deaf or hard of hearing, you may call the TTY number, 1-800-325-0778 between 7:00 a.m. and 7:00 p.m. Eastern time, Monday through Friday. We can answer most of your questions over the phone. When you call, please have this letter with you to help us answer your questions.

If you have questions about reporting income or Form 1099-MISC, please contact the Internal Revenue Service.

GN 03905.055 Invalid Appointment Forms

A. When to use

Sometimes representatives submit notices of appointment (e.g. form SSA-1696 or "equivalent writing") before a claimant submits an application for benefits. When we receive these notices, we will return them unprocessed together with the notice REP028 available in the Document Processing System (DPS).

B. Exhibits

1. Appointment Documents Returned - No Pending Claim

We are returning the appointed representative forms you submitted for [INSERT: Claimant’s Name]. We could not process the forms because [INSERT: Claimant’s Name] does not have a matter pending before us, such as a post-entitlement issue, or a pending claim on file or appeal.

If your client intends to file a claim for benefits, an appeal or other matter, or you submitted an iClaim on their behalf, please re-submit your documents once this matter is filed.

Suspect Social Security Fraud?

Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at

1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free

at 1-800-772-1213, or call your local Social Security office at 866-331-2307. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

SOCIAL SECURITY

STREET

CITY, STATE ZIP

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment.

This will help us serve you more quickly when you arrive at the office.

 

GN 03905.060 Form SSA-1693 Fee Agreement for Representation before SSA

A. When to use

Appointed representatives, who want to charge and collect a fee for services before us, can use one of the two mutually exclusive fee authorization processes: the fee agreement process or the fee petition process. Representatives have the option to use this form when they want to charge a fee under the fee agreement process.

B. Exhibit

See Form SSA-1693 to obtain the most current PDF.

GN 03905.065 Exhibits for Fee Authorization under the Fee Agreement Process

A. When to use

We use these templates in the fee authorization process either to authorize the fee or to contact the hearing or Appeals Council offices when further actions on fee agreement determinations are necessary.

B. Exhibits

1. Sample Language for Fee Agreement Determination (Form SSA-553 Special Determination)

I. FEE AGREEMENT APPROVED:

I approve the fee agreement between the claimant and his or her representative provided that the claim results in past-due benefits.

My determination is limited to whether the fee agreement meets the statutory condition for approval and is not otherwise excepted.

I neither approve nor disapprove any other aspect of the fee agreement.

II. FEE AGREEMENT DISAPPROVED:

I do not approve the fee agreement between the claimant and his or her representative because:

[Check only those that apply]

____SSA did not receive the written agreement before deciding the claim.
____The claimant and his or her representative(s) all did not sign the fee agreement.
____The fee agreement sets a fee that is more than the lesser of 25 percent of the past-due benefits or the applicable specified dollar amount of the fee cap as outlined in GN 03940.003B.3 (e.g., $6,000).
____The claimant appointed more than one representative, all did not sign a single fee agreement, and the non-signing representative(s) did not waive charging or collecting a fee.
____The claimant discharged a representative, or a representative withdrew from the case before we decided the claim, and the representative did not waive charging or collecting a fee.
____A State court declared the claimant legally incompetent and the claimant's legal guardian did not sign the fee agreement.
____There are no past-due benefits.
Prior or Subsequent Applications with Multiple Representatives
____Considering the appointments of representative in the claimant's applications dated [Date of prior application] and [Date of subsequent application], the claimant appointed more than one representative, all did not sign a single fee agreement, and the non-signing representative(s) did not waive charging or collecting a fee.
____Considering the appointments of representative in the claimant's applications dated [Date of prior application] and [Date of subsequent application], the claimant has been declared legally incompetent and the claimant's legal guardian did not sign the fee agreement.

2. Regional Chief Administrative Law Judges' addresses and codes of the Hearing Offices within their Jurisdictions

For the Office of Hearing Operations (OHO) fee agreement issues, see OHO Fee Contacts for a current list of regional chief administrative law judges' addresses and the codes of the hearing offices within their jurisdictions.

NOTE: For a National Hearing Center (NHC) case, send any protest memorandum to the Office of the Regional Chief Administrative Law Judge that has jurisdiction over the region where the claimant is currently residing.

3. Sample Follow-up Memorandum - No Fee Agreement Determination

MEMORANDUM TO:

(Name of the Hearing Office Director)

(City in which the hearing office is located)

or

(Name of AAJ)

Administrative Appeals Judge

Through: Attorney Fee Branch

Office of Appellate Operations

5107 Leesburg Pike, Suite 805 Skyline

Falls Church, Virginia 22041-3255

FROM:

(Title of PC Official)

(PC Involved, e.g., NEPSC, ODO)

SUBJECT:

Determination on Fee Agreement - ACTION

(Claimant's Name and SSN);

On (Date of telephone contact), we advised (the [specify which hearing office] hearing office/your office) by (telephone/e-mail) that the file in the subject claim does not contain a determination on the fee agreement in this case. We asked (the hearing office/your office) to forward a determination on the fee agreement to us within 15 days.

We are unable to authorize a fee for the representative's services until we receive a determination on the fee agreement.

[Use the following paragraph if the representative is an attorney and SSA is withholding past-due benefits for direct fee payment:]

We are withholding $(Amount of past-due benefits withheld for direct payment) of the claimant's past-due benefits for direct payment of a fee to the representative. However, we cannot release any of the withheld funds until we receive the determination on the fee agreement.

Please (request the ALJ to) email the determination to us as soon as possible (fax number [fax number]). If you have any questions, please contact (Name of PC contact) at (Telephone number and email address of PC contact).

(Signature of PC Official)

(Printed Name of PC Official)

cc: [(If addressee is HOD) ALJ]

[(If addressee is AAJ) Deputy Chair, Appeals Council]

Attachments

4. Memorandum to the Regional Chief ALJ - Fee Agreement Approved Incorrectly - ALJ hearing level

MEMORANDUM TO:

Regional Chief Administrative Law Judge

(Address)

FROM:

(Title of PC Official)

(PC Name and Address)

SUBJECT:

Fee Agreement Determination - ACTION

(Claimant's Name and SSN)

On (date), Administrative Law Judge (name) signed an order approving the fee agreement in this case. We do not believe that the approval is correct for the following reason(s). (List Reason(s).)

Copies of the favorable decision, the appointment(s) of representative(s), the fee agreement(s), the order approving the fee agreement, and (any additional relevant information) are available in the electronic folder for your review and action.

We are withholding $(amount) of the claimant's past-due benefits for direct payment to the representative.

Please email your determination to us as soon as possible (email address). If you have any questions, please contact (name of contact) at (contact number/email address).

(Signature of PC Official)

(Name Printed)

Attachments

5. Memorandum to the Deputy Chair, Appeal Council - Fee Agreement Approved Incorrectly - Appeals Council Review level

MEMORANDUM TO:

Deputy Chair, Appeals Council

Office of Appellate Operations

5107 Leesburg Pike, Suite 1400 Skyline

Falls Church, Virginia 22041-3255

FROM:

(Title of PC Official)

(PC Name and Address)

SUBJECT:

Fee Agreement Determination - ACTION

(Claimant's Name and SSN)

On (date), Administrative Appeals Judge (name of AAJ) signed an order approving the fee agreement in this case. We do not believe that the approval is correct for the following reason(s). (Reasons.)

Copies of the favorable decision, the appointment(s) of representative(s), the fee agreement(s), the order approving the fee agreement, and (any additional relevant information) are available in the electronic folder for your review and action.

We are withholding $____ of the claimant's past-due benefits for direct payment to the representative.

Please send your determination to us as soon as possible. If you have any questions, please contact us at (contact information).

(Signature of PC Official)

(Name Printed)

Attachments

GN 03905.070 Form SSA-1560 Petition to Obtain Approval of a Fee for Representing a Claimant

A. When to use

Appointed representatives, who want to charge and collect a fee for services before us, must use one of two mutually exclusive fee processes: the fee agreement process or the fee petition process. Representatives have the option to use this form when they want to charge a fee under the fee petition process. The representative also sends a copy to the claimant.

B. Exhibits

See Form SSA-1560 to obtain the most current PDF.

GN 03905.075 Fee Petition Processing Notices

A. When to use

When a representative submits a fee petition before completing his or her services on a pending claim, we return the fee petition and advise the representative, using the notice in exhibit 1 below, that we cannot accept the requests until after representation has ended.

If there is no evidence to show the claimant received a copy of the fee petition, we use the notice in exhibit 2 below, to advise the claimant that the representative filed a fee petition.

B. Exhibits

1. Fee petition filled prematurely

You recently requested approval of a fee for representing (claimant's name). We are returning your fee request because you told us that you have not completed your services for (Mr./Ms. claimant's last name). We cannot address your fee request until your services in this case have ended.

What You Should Do

After your services in this case have ended, please send us a new fee request. You may use the enclosed Form SSA-1560-(Petition For Authorization To Charge And Collect A Fee For Services Before The Social Security Administration). The following sections of the Code of Federal Regulations explain when and how to request a fee:

  • 20 CFR 404.1725(a) for Social Security cases

  • 20 CFR 416.1525(a) for Supplemental Security Income cases

If You Have Any Questions

If you have any questions about this letter, please write us at the above address. If you have any questions about other Social Security matters, call us toll free at 1-800-772-1213, 7 a.m. to 7 p.m., Monday through Friday. We can answer most questions over the phone. Our busiest times are the first week of the month and Mondays. So, we may be able to handle your call more quickly if you call us at other times.

If you wish, you can call your local Social Security office at xxx-xxx-xxxx. You can also write or visit a Social Security office. The office that serves your area is located at:

Street Address

City, State ZIP

Enclosures:

Premature Fee Request

Form SSA-1560-U4

If you do call or visit an office, please have this letter with you. It will help us answer your questions. This will help us serve you more quickly.

Assistant Regional Commissioner,

Processing Center Operations

cc:

Claimant's Name

2. Claimant was not provided a copy of the petition

(Representative's Name) recently asked us to approve a fee of $(dollar amount) for representing you in your case before Social Security. We have enclosed a copy of this request.

Please let us know if you disagree with the fee requested or any information shown in the request. If you disagree, you must contact us within 20 days of receiving this letter. We will not address (Mr./Ms. representative's last name)’s request until after that time.

You may call us about this matter at (area code and phone number), or write to us using the enclosed self-addressed envelope. If you have questions about other Social Security matters, you may call us toll free at 1-800-772-1213, or call your local Social Security office at xxx-xxx-xxxx. We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

Street Address

City, State ZIP

If you do call or visit an office, please have this letter with you. It will help us answer your questions. This will help us serve you more quickly.

Assistant Regional Commissioner,

Processing Center Operations

Enclosures:

Fee Request

Self-addressed Envelope

cc:

Representative's Name

 

GN 03905.080 Form SSA-1178 Evaluation of Fee Petition for Representation

A. When to use

Processing centers and the Office of Hearings Operations, and the Office of Appellate Operations may use this form, primarily in the fee petition process, to explain and document the rationale for authorizing a reasonable fee in the specified amount.

B. Exhibit

See Form SSA-1178 to obtain the most current PDF.

GN 03905.085 Form SSA-1560A Authorization to Charge and Collect a Fee

A. When to use

Processing centers, the Office of Hearing Operations, and the Office of Appellate Operations use this form to notify claimants and their representatives of the authorized fee amount for the representatives' services under the fee petition process.

B. Exhibit

See form SSA-1560A to obtain the most current PDF.

GN 03905.090 Notice for Direct Fee Payment to Representative from TXVI Past-Due Benefits

A. When to use

We use this notice to inform Title XVI claimants and their representatives that we are withholding benefits to pay representatives their authorized fee.

B. Exhibits

We are writing to tell you more about the fee we authorized your representative to charge for his or her services on your Supplemental Security Income (SSI) claim.

Information About Past-Due Benefits Withheld to Pay Your Representative

  • Your representative is eligible to receive direct payment of the fee we approve. We withheld money from your past-due benefits to pay the representative.

  • The fee that the representative is approved to charge is $1,600.

  • We are paying the representative from the benefits we withheld.

  • Because we are paying the fee from your benefits, we must collect a service charge from the representative. The service charge is 6.3 percent of the fee amount we pay, but not more than $95.00, 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 representative. This means that we subtract $95 from the $1,500 we are paying toward the representative’s fee, and send him or her $1,405.

The representative cannot ask you to pay for the service charge. If the representative disagrees with the amount of the service charge, he or she must write to our address shown above. The representative must tell us why he or she disagrees within 15 days from the day he or she gets this letter.

The fee we approved is more than the money we withheld and paid to your representative. Payment of the remainder of the approved fee, $100, is a matter between you and your representative.

NOTE: The assessment paragraph at the fourth bullet will vary depending on the circumstances in the claim. Refer to GN 03920.019K, Procedure – Notice Language.)

 


GN 03905 TN BASIC - Forms, Exhibits and Notices for Representatives - 12/10/2019