The benefit authorizer will request and provide the appropriate fill-ins for this
notice.
Send a copy of the notice to the representative.
Fill-ins:
(1) Choice 1 – you (if sending the notice to the number holder (NH) or represented
auxiliary)
Choice 2 – NH full name (if sending the notice to an unrepresented auxiliary)
(2) Representative’s name
(3) Choice 1 – your [if choice 1 selected for fill-in (1)]
Choice 2 – his [if choice 2 selected for fill-in (1) and the NH is male]
Choice 3 – her [if choice 2 selected for fill-in (1) and the NH is female]
(4) Same as fill-in (3)
(5) Choice 1 – your (if sending the notice to the NH or represented auxiliary)
Choice 2 – “NH’s full name possessive” and “and your” (if sending the notice to an
unrepresented auxiliary)
(6) amount that should have been withheld from this individual (lesser of 25% of past
due benefits or the authorized fee in fill-in (7))
(7) amount of authorized fee owed by this individual