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.

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.

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.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0203905005

GN 03905.005 - Representation Referral List Model Notice - 12/10/2019
Batch run: 08/25/2025
Rev:12/10/2019

Program Operations Manual System (POMS)

GN 03905.005 Representation Referral List Model Notice

A. When to use

B. Sample notice