As the representative of John Doe in his claim for entitlement to social security
benefits under John Doe, you were authorized a fee for your services in the amount
of $6,000. Through error, we made a duplicate payment to you, and you received $6,000
in excess of the fee authorized to you.
As a result, you owe the Social Security Administration $6,000. 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
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), which may warrant proceedings to suspend or disqualify you from practicing
before SSA, under 20 CFR 404.1745 and 20 CFR 416.1545.
FO Manager or PC Manager (no signature needed, title only)
Copies of the United States Treasury checks issued to the Representative
Self-addressed, Unfranked return envelope