TN 10 (07-97)
GN 03940.080 Fee Agreement Process - Title II - Delayed Auxiliary Claim(s) Paragraphs
Paragraph ATYR20
Fee Amount - Title II Claim Only - Number Holder (N/H) Only -Delayed Auxiliary Claim(s)
Pending or Expected - N/H's Award Notice
Information About Representative's or Lawyer's Fees
We base the amount of your (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, your (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 your (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 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 you and your (7) .
Fill-ins:
-
(1)
Choice 1 - representative's
Choice 2 - lawyer's
-
(2)
The amount of the N/H's past-due benefits
-
(3)
Choice 1 - Month/Year
Choice 2 - Month/Year through Month/Year
-
(4)
Choice 1 - representative
Choice 2 - lawyer
-
(5)
The amount of the fee based on N/H's past-due benefits
-
(6)
Choice 1 - representative
Choice 2 - lawyer
-
(7)
Choice 1 - representative
Choice 2 - lawyer
Paragraph ATYR22
Fee Amount - Title II Claim Only - N/H and Non-delayed Auxiliary Beneficiary(ies)
- Delayed Auxiliary Claim(s) Pending or Expected - N/H's Award Notice
Information About Representative's or Lawyer's Fees
We base the amount of your (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, your (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 your (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 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 you and your (13) .
Fill-ins:
-
(1)
Choice 1 - representative's
Choice 2 - lawyer's
-
(2)
The amount of the N/H's past-due benefits
-
(3)
Choice 1 - Month/Year
Choice 2 - Month/Year through Month/Year
-
(4)
Choice 1 - [Current action involves only one auxiliary beneficiary] - Insert possessive
case of name of auxiliary beneficiary in the format First Name, Last Name. Example:
Henry James'
Choice 2 - [When current action involves two or more auxiliary beneficiaries with
same pay period] Insert - Your family's
-
(5)
The amount of the non-delayed auxiliary beneficiary's(ies') past-due benefits
-
(6)
Choice 1 - Month/Year
Choice 2 - Month/Year through Month/Year
-
(7)
Choice 1 - representative
Choice 2 - lawyer
-
(8)
Choice 1 - [Current action involves only one auxiliary beneficiary] - Insert name
of auxiliary beneficiary in the format First Name, Last Name. Example: Henry James
Choice 2 - [When current action involves two or more auxiliary beneficiaries with
same pay period] Insert - your family
-
(9)
The amount of the fee based on total past-due benefits for the N/H's claim and any
non-delayed auxiliary claims
-
(10)
Choice 1 - spouse's claim
Choice 2 - other child's claim
Choice 3 - other children's claims
Choice 4 - spouse's and other child's claims
Choice 5 - spouse's and other children's claims
-
(11)
Choice 1 - him
Choice 2 - her
Choice 3 - them
-
(12)
Choice 1 - representative
Choice 2 - lawyer
-
(13)
Choice 1 - representative
Choice 2 - lawyer
Paragraph ATYR24
Fee Amount - Concurrent Titles II and XVI Claims Offset Information Pending - Delayed
Auxiliary Claims(s) Pending or Expected -N/H's Award Notice
Information About Representative's or Lawyer's Fees
We base the amount of your (1) fee on the total past-due benefits for you and your family. Under the fee agreement,
your (2) can charge you $ (3) 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 your (4) 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 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 you and your (5) .
Fill-ins:
-
(1)
Choice 1 - representative's
Choice 2 - lawyer's
-
(2)
Choice 1 - representative
Choice 2 - lawyer
-
(3)
The amount of the fee based on N/H's past-due benefits
-
(4)
Choice 1 - representative
Choice 2 - lawyer
-
(5)
Choice 1 - representative
Choice 2 - lawyer
Paragraph ATYR26
Fee Amount - Concurrent Titles II and XVI Claims Offset Information Pending - N /H
and Non-Delayed Auxiliary Beneficiary(ies) -Delayed Auxiliary Claims Pending or Expected
- N/H's Award Notice
Information About Representative's or Lawyer's Fees
We base the amount of your (1) fee on the total past-due benefits for you and your family. Under the fee agreement,
your (2) can charge you and (3) $ (4) for his or her work. As soon as we make a decision on your (5) and decide the amount of the past-due benefits, we will tell (6) if your (7) 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 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 you and your (8) .
Fill-ins:
-
(1)
Choice 1 - representative's
Choice 2 - lawyer's
-
(2)
Choice 1 - representative
Choice 2 - lawyer
-
(3)
Choice 1 - [Current action involves only one auxiliary beneficiary] - Insert name
of auxiliary beneficiary in the format First Name, Last Name. Example: Henry James
Choice 2 - [When current action involves two or more auxiliary beneficiaries with
same pay period] Insert- your family
-
(4)
The amount of the fee based on the N/H's and any non-delayed auxiliary's(ies') past-due
benefits
-
(5)
Choice 1 - spouse's claim
Choice 2 - other child's claim
Choice 3 - other children's claims
Choice 4 - spouse's and other child's claims
Choice 5 - spouse's and other children's claims
Choice 6 - family's claim
-
(6)
Choice 1 - him
Choice 2 - her
Choice 3 - them
-
(7)
Choice 1 - representative
Choice 2 - lawyer
-
(8)
Choice 1 - representative
Choice 2 - lawyer