We are writing to let you know about a change in the amount of the fee (1) can collect from (2) monthly benefits for serving as (3) representative payee.

What (4) Representative Payee Can Collect

Representative payees may collect a fee of 10 percent of a person's total monthly benefits but no more than $ (5) each month. However, they can collect up to $ (6) each month if the person is receiving disability benefits and drug addiction and/or alcoholism is a contributing factor material to that disability.

We are sending a copy of this notice to (7) representative payee.

If You Have Any Questions

3765C

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  Send this notice to inform a legally competent adult, emancipated minor, legal guardian, or parent or person standing in place of parent when the amount of the fee the representative payee has been authorized to collect changes because the beneficiary's DAA status changes.

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  Show the title of the officer and the name of the institution or entity. Do not show the name of such officer.

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  Use paragraph 3774A when the fee amount increases because the beneficiary is now DAA.

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  Use paragraph 3774B when the fee amount decreases because the beneficiary is no longer DAA.

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  Use paragraph 3774C when the fee amount decreases because the beneficiary's DAA is no longer material to the disability.

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  Refer to NL 00703.765 for 3765C text and fill-ins.

   

Fill-ins