Dear [Representative’s Name]:
This letter concerns the fee payment you received for your services on behalf of [Claimant’s
Full Name].
As the representative of [Claimant’s Full Name] in his claim for [Type of Benefit]
benefits, you received a fee of [Amount Paid] for your services. Your correct authorized
fee is [Authorized Fee]. After deducting the required assessment, we find that you
received [Excess Dollar Amount] more than your authorized fee.
As a result, you owe the Social Security Administration [Excess Dollar Amount Owed
to SSA]. Please refund this amount within 30 days from the date of this notice. Make
your refund payable to the “Social Security Administration.” Include the claimant’s
full name and full Social Security Number (SSN) on your refund. Mail your refund using
the enclosed envelope to:
[FO or PC Return Address]
If you fail to refund this amount, we may refer the matter to the Office of the General
Counsel as a potential violation of our fee collection rules in 20 CFR 404.1740(c)
and 20 CFR 416.1540(c). A violation may warrant proceedings to suspend or disqualify
you from practicing before SSA under 20 CFR 404.1745 and 20 CFR 416.1545.
Social Security Administration
Enclosures:
Self-addressed, unfranked return envelope