We told you in another letter that your lawyer could charge you no more than $ (1) , under the fee agreement, for his or her work on your Social Security claim. We also explained your right to review the amount of the fee.

What We Are Paying Your Lawyer

Because no one asked us to review the amount of the fee, we are paying your lawyer
$ (2) . This means we are paying your lawyer in full for the work on your Social Security claim.

(3) lawyer may be able to charge an additional amount for his or her work on (4) Supplemental Security Income (SSI) claim. We will send you another letter, about SSI, telling you the additional fee amount, if any, (5) lawyer can charge.

We will let you know later how much we must withhold from your benefits for (6) because of the Supplemental Security Income you received.

If You Have Any Questions

3901C

• •

  The Benefit Authorizer (BA) or Claims Authorizer (CA) will request this notice for the number holder in concurrent title II/title XVI fee agreement cases when withheld past due benefits are being released to the attorney and offset information is pending. Do not date and release this notice until the payment is actually processed.

   

• •

  Fill-ins:

  1. (1) 

     amount of the fee

  2. (2) 

     amount of the fee

  3. (3) 

     Choice 1 - Your (if NH)

     Choice 2 - The (if auxiliary)

  4. (4) 

     Choice 1 - your (if NH)

     Choice 2 - the (if auxiliary)

  5. (5) 

     Choice 1 - your (if NH)

     Choice 2 - the (if auxiliary)

  6. (6) 

     Month/Year through Month/Year of Prior Month Accural (PMA)