We withheld $ (1) of (2) past-due benefits for representative’s fees. We withheld this amount as of (3). This amount is 25 percent of (4) past-due benefits.

Earlier we told you to send us a fee petition if you wanted us to pay your fee directly from your client’s past-due benefits. We have not received your fee petition or a statement that you are not charging a fee.

We do not wish to delay the release of the withheld benefits to your client.

What You Need To Do

If you are charging a fee, you need to file a fee petition or written request for an extension within 20 days from the date of this notice.

If you are not charging a fee, you must send us a statement to that effect.

If we do not hear from you within 20 days from the date of this notice, we will release the withheld benefits to your client.

Where To Submit the Information

You may get the form SSA-1560-U4 (Petition to Obtain Approval of a Fee for Representing a Claimant Before the Social Security Administration) at (5).

Please forward your petition, written request for an extension of time, or statement that you will not charge a fee to:

(6)

You must send a copy of your petition, written request for an extension of time, or a statement that you will not charge a fee to your client.

Important Reminder

Any fees you want to charge from now on for your services on (7) case are subject to the agency’s authorization. Failure to comply with this requirement could result in a violation of section 206(a) of the Social Security Act. Collection of any such approved fee will be a matter between you and your client.

We are sending a copy of this letter to your client.

• •

  The reconsideration reviewer is responsible for requesting this notice and providing the appropriate fill-ins. See GN 03920.060B.2. for usage information.

   

• •

  Fill-ins:

  1. (1) 

     amount withheld

  2. (2) 

     Name(s) of beneficiary [possessive]

  3. (3) 

     Month YYYY

  4. (4) 

     (Same as 02) Name(s) of beneficiary [possessive]

  5. (5) 

     SSA-1560

  6. (6) 

     PSC address (Add 5 lines of address)

  7. (7) 

     Same as 02) Name(s) of beneficiary [possessive]

Use SSA-L2000-C2 (Universal Notice) or an SSA-L951-C2 (Social Security Notice) for the first page, and plain bond paper for the second page, when needed.