TN 3 (03-95)
GN 03960.090 Exhibit - Decision Maker Request for Administrative Review and Transmittal
|
MEMORANDUM TO
|
: NE MAT SE GL WN MAM ODIO Processing Center
|
REGARDING |
: |
. - - ,
|
|
|
|
Account # & Symbol
|
Name of Wage Earner or Beneficary
|
FROM |
: |
|
|
|
SUBJECT
|
:
|
Request for Administrative Review of Fee Based on an Approved Fee Agreement — ACTION
|
I approved the fee agreement between
(Name of Claimant)
and .
(Name of Representative)
I ask for a reduction of the fee which would otherwise result under the agreement
because, I believe, the evidence shows:
(Designate One)
/ / the fee is clearly excessive in light of the services provided
/ / did not represent the claimant's interest adequately.
Name of Representative
My reasons follow.
Attachment(s) / / Yes / /No
cc: |
|
, Claimaint |
|
|
, Representative |
|
|
, Auxiliary Beneficary(ies) |
|