We show that (1) chose (2) as (3) representative in (4) claim for Social Security benefits. By law, we must hold back up to 25 percent of (5) past-due benefits to pay the representative. However, we released this money to you in error.

We should have held $(6) from the benefits you received to pay all or part of the fee. Since we released these benefits to you, the representative will look to you for payment of your share of the fee. Your share of the authorized fee is $(7).

The representative may contact us at the above address if you do not pay the fee. If the representative contacts us to collect payment from you, we will:

• •

  pay the representative the amount we should have held from you, minus any service charge we must keep by law; and

• •

  recover from you the amount we should have held.

If the authorized fee is more than the amount we should have held, you must pay any remaining fee balance.

We will send the representative a copy of this notice.

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

Use Form SSA-L2000-C2 (Universal Notice) or a Form SSA-L951-C2 (Social Security Notice) for this notice.