Prepare, or instruct the typist to prepare, the form as follows:
NOTE: Prepare more than one Form SSA-1560A-U5 when there is more than one family unit.
-
a.
Enter the identifying information, including the sender. If one or more auxiliary
beneficiaries are involved, add “and Family” after the claimant's name. If the title
XVI spouse is involved, add “and Spouse.”
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b.
Enter the representative's name and address. If the representative is an attorney,
use one of the following with the address:
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•
( Mr. or Ms. ) ( Name )
Attorney at Law
( Address )
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•
( Name ), Esq.
( Address )
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c.
Enter the fee amount. Make sure it agrees with the amount finally authorized, as shown
on the SSA-1178.
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d.
Enter the address to which a party must send any request for administrative review.
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e.
Designate the appropriate paragraph about the means of fee payment, as well as the
reference to the attached notice.
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f.
Enter the name and address of the claimant or auxiliary beneficiary(ies).
EXCEPTION: Do not complete Form SSA-1560A-U5 or the electronic version of the form if GN 03930.105D.2. applies (i.e., you are recommending a fee greater than $12,000).