We are writing to tell you that you are entitled to (1) benefits from Social Security beginning (2) . However, we cannot pay you all your back benefits now because we may have to pay your lawyer for work on your claim. The following information explains what this means to you.

 

What We Will Pay And When

• •

  You will soon receive a check for $ (3) .

• •

  This is money you are due for (4) , minus the money withheld to pay for your legal expenses.

• •

  We withheld $ (5) , or 25 percent of your back benefits, in case we have to pay your lawyer.

• •

  We will write to you later about your regular monthly check when we finish working on your claim.

   

What We Will Pay Your Lawyer

Your lawyer has to ask us to approve any fee for work done. Your lawyer has 60 days to let us know that a fee will be charged. If we approve the fee:

• •

  We will pay your lawyer directly, using the $ (6) we withheld from your benefits.

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  If the fee is less than the money we withheld, we will pay you any extra money that is left.

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  If the fee is more than the money we withheld, you will need to arrange to pay your lawyer the difference.

We are sending a copy of this letter to your lawyer.

 

If You Have Any Questions

3901C - Domestic

3901D - Foreign

• •

  This letter is sent where a delay in the issuance of a Notice of Award is expected, and 25 percent of the retroactive benefits is being withheld because of attorney involvement. The claimant will have already been informed about how attorney fees are deducted from retroactive benefits at the time when the attorney fee agreement (SSA-1696-U4) was signed. This letter is a notification that 25 percent of retroactive benefits is being withheld, and that the disposition of this money will be completed after the attorney has submitted a fee request.

   

• •

  Fill-ins:

  1. (1) 

     type of benefits awarded, for example “disability”

  2. (2) 

     date of entitlement, e.g., January 1992

  3. (3) 

     amount of retroactive benefits, less 25% withholding

  4. (4) 

     months for which retroactive benefits are due, e.g., January 1992; January and February 1992; January through March 1992

  5. (5) 

     amount withheld

  6. (6) 

     amount withheld

• •

  Refer to NL 00703.005 E. for 3901C and 3901D text and fill-ins.

Use Form SSA-L2000-C2 (Universal Notice) and follow notice standards. Information for this notice will be shown on Form SSA-573.