We are writing to tell you that we have approved a fee of $ (1) to pay your representative for the work on your Social Security claim. We explained
this fee, and your right to question it, in an earlier letter.
What We Will Pay Your Representative
Insert one of the following optional paragraphs:
3816 A (approved fee exactly equals withheld benefits):
We withheld $ (1) from your benefits to pay your legal expenses. Since we have approved the fee, we
are sending your representative this money. This means we have paid your representative
in full for the work done on your claim.
If we issued your decision after January 31, 2000, we must charge your representative
the maximum user fee or 6.3 percent of the amount we pay him or her from your past-due
benefits. Your representative cannot charge or collect this expense from you. We will
subtract the charge from the amount payable to the representative and send him or
her the remainder. If your representative disagrees with this charge, he or she may
write to the address on this letter; and tell us why he or she disagrees.
We are sending a copy of this letter to your representative.
3816 B (approved fee is less than withheld benefits):
We withheld $ (1) from your benefits to pay your legal expenses. We will send $ (2) of this money to your representative. This means we have paid your representative
in full for the work on your claim. We will send the balance of $ (3) to you. You should receive this check soon.
If we issued your decision after January 31, 2000, we must charge your representative
the maximum user fee or 6.3 percent of the amount we pay him or her from your past-due
benefits. Your representative cannot charge or collect this expense from you. We will
subtract the charge from the amount payable to the representative and send him or
her the remainder. If your representative disagrees with this charge, he or she may
write to the address on this letter; and tell us why he or she disagrees.
We are sending a copy of this letter to your representative.
3816 C (approved fee is more than withheld benefits):
We withheld $ (1) from your benefits, and we are sending this money to your representative. But this
does not cover the entire fee. You and your representative will need to decide how
to settle the additional $ (2) you owe.
If we issued your decision after January 31, 2000, we must charge your representative
the maximum user fee or 6.3 percent of the amount we pay him or her from your past-due
benefits. Your representative cannot charge or collect this expense from you. We will
subtract the charge from the amount payable to the representative and send him or
her the remainder. If your representative disagrees with this charge, he or she may
write to the address on this letter; and tell us why he or she disagrees.
We are sending a copy of this letter to your representative.
3816 D (concurrent Title II and Title XVI case subject to windfall offset)
Your SSI Payments May Change
Please contact us to find out if we can pay _(1)_ more Supplemental Security Income (SSI) money. We can subtract the fee we paid to
(2) representative from the income we count to figure (3) SSI payment. When we subtract the fee, we might be able to pay (4) more money.
If You Have Any Questions
3901C - Domestic
3901D - Foreign