We are writing to tell you that we are sending you a payment for $ (1) . We withheld this money from your benefits to pay your appointed representative(s).
We are sending you this money now because your appointed representative(s) told us
that he or she would not charge you for services performed on your claim.
We are sending a copy of this letter to your appointed representative(s).
If You Have Any Questions
3901C - Domestic
3901D - Foreign