(Name of the Hearing Office Director)
(City in which the hearing office is located)
(Name of AAJ)
Administrative Appeals Judge
ATTN: Attorney Fee Branch
Office of Appellate Operations
6401 Security Blvd.
Baltimore, MD 21235-6401
(Title of PC Official)
(PC Involved, e.g., NEPSC, ODO)
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
We are unable to authorize a fee for the representative's services until we receive
a determination on the fee agreement.
the following paragraph if the representative is an attorney and SSA is withholding
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)
addressee is HOD) ALJ]
addressee is AAJ) Deputy Chair, Appeals Council]