Date:
               Dear _____________:
               You were authorized a fee for your representational services to [claimant's name]
                  in the amount of $8,000. Through error, we made a duplicate payment to you, and you
                  received $8,000 [subtract any user fee if applicable] in excess of the fee authorized
                  to you.
               
               As a result, you owe the Social Security Administration $8,000 [subtract any user
                  fee if applicable]. Please refund this amount within 30 days from the date of this
                  notice. Make your refund payable to the “Social Security Administration” and include
                  the claimant’s full name and full Social Security Number (SSN) on your refund. Mail
                  the refund to: [Insert the FO’s or PC’s address].
               
               If you fail to comply in a timely manner, we may refer the matter to the Office of
                  the General Counsel as a potential violation of our fee collection rules at [20 CFR
                  404.1740(c) and/or 20 CFR 416.1540(c)], which may result in proceedings to suspend
                  or disqualify you from practicing before SSA under 20 CFR 404.1745 and 20 CFR 416.1545.
               
               Social Security Administration
                
               Enclosures:
               Copies of the United States Treasury checks issued to the Representative
               Self-addressed, Unfranked return envelope