TN 17 (03-05)
GN 03940.075 Title II - Fee Agreement Process – Neutral Language Paragraphs – Fee Authorization
Deferred
Paragraph A: ATYR04;
Claimant/Auxiliary Notice – Partial Adjudication - Representative Eligible for Direct
Payment
When a (1) wants to charge for helping with a Social Security claim, we must approve the fee.
We usually withhold 25 percent of past-due benefits in order to pay the approved (2) fee. We withheld $ (3) from (4) in case we need to pay (5) (6).
We cannot tell you how much the (7) can charge at this time. When processing (8) claim we found we needed more information. To decide how much (9) benefits will be for (10), we need (11) (12) (13). When we get that information, we will decide the amount of (14) past-due benefits and send another letter telling you how much the (15) can charge. You can help us finish the work on (16) claim by taking the information to any Social Security office.
Fill-ins
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1.
always use representative
-
2.
always use representative's
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3.
show the total fee amount withheld from all PICs/Show the single PICs fee amount withheld
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4.
the benefits due you and your family/your benefits
-
-
6.
always use representative
-
7.
always use representative
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8.
Ms. plus BLN (possessive)/ Mr. plus BLN (possessive) your
-
-
10.
Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY
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11.
Manual fill-in 1 which can include choices A or B
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-
-
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13.
Manual fill-in 2 which can include choices of workers' compensation benefits/public
disability benefits/workers' compensation and public disability benefits/military
service/date of birth/or free format reason*
-
-
15.
always use representative
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Paragraph B: ATYR06; PCNATY002
Claimant/Auxiliary Notice – Partial Adjudication - Non-attorney Representative Ineligible
for Direct Payment
When a representative wants to charge for helping with a Social Security claim, we
must approve the fee.
We cannot tell you how much the representative can charge at this time. When processing
(1) claim we found we needed more information. To decide how much (2) benefits will be for (3) , we need (4) (5) (6) . When we get that information, we will decide the amount of (7) past-due benefits and send another letter telling you how much the representative
can charge. You can help us finish the work on (8) claim by taking the information to any Social Security office.
Fill-ins
-
1.
Choice 1 - Ms. + BLN (possessive)
Choice 2 - Mr. + BLN (possessive)
Choice 3 - your
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2.
Choice 1 - her
Choice 2 - his
Choice 3 - your
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3.
Choice 1 - Month, year
Choice 2 - Month, year and month, year
Choice 3 - Month, year through month, year
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4.
Choice 1 - proof of
Choice 2 - more information about
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5.
Choice 1 - her
Choice 2 - his
Choice 3 - your
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6.
Manual fill-in, e.g., worker's compensation benefits, state disability benefits, military
service, date of birth
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7.
Choice 1 - her
Choice 2 - his
Choice 3 - your
-
8.
Choice 1 - her
Choice 2 - his
Choice 3 - your
Paragraph C: ATYR21: Claimant Notice – ALJ or AAJ may have incorrectly approved fee agreement
–Representative Eligible for Direct Payment
When a representative wants to charge for helping with a Social Security claim, we
must approve the fee. We usually withhold 25 percent of past-due benefits in order
to pay the approved representative's fee. We withheld $_(1)_ from _(2)_ in case we need to pay your representative.
When we decide the amount of the fee, we will let you and the representative know
how much of this money will be used to pay the fee. We will send any remainder to
_(3)_.
Fill-ins
-
1.
The amount of past-due benefits withheld
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2.
Choice 1 – your past-due benefits
Choice 2 – the past-due benefits due you and your family
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3.
Choice 1 – you
Choice 2 – you and your family
Paragraph D: ATYR23: Auxiliary Notice (Auxiliary Not Living in the Same Household With Primary
Claimant) – ALJ or AAJ may have incorrectly approved fee agreement - Representative
Eligible for Direct Payment
When a representative wants to charge for helping with a Social Security claim, we
must approve the fee. We usually withhold 25 percent of past-due benefits in order
to pay the approved representative's fee. We withheld $_(1)_ from _(2)_ past-due benefits in case we need to pay _(3)_ representative.
When we decide the amount of the fee, we will let you and the representative know
how much of this money will be used to pay the fee. We will send any remainder to
you.
Fill-ins
-
1.
The amount of past-due benefits withheld
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2.
Choice 1 – your
Choice 2 – beneficiary's name (possessive case)
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3.
Number holder's name, first and last (possessive case)
Paragraph E: ATYR25: Claimant/Auxiliary Notice – ALJ or AAJ may have incorrectly approved fee
agreement - Non-attorney Representative Ineligible for Direct Payment
When a representative wants to charge for helping with a Social Security claim, we
must first approve the fee. When we decide the amount of the fee, we will let you
and your representative know how much money he or she can charge you for the work
on your claim.