We are writing to tell you that we are sending you a payment for $ (1) . We withheld this money from your benefits to pay for your appointed representative(s).

We are sending you this money now because your appointed representative(s) did not ask us to approve a fee.

Your appointed representative(s) may decide later to charge a fee for services performed on your claim. If this happens, we will need to approve the fee he or she charges you, and you will have to pay them directly.

We are sending a copy of this letter to your appointed representative(s).

If You Have Any Questions

3901C - Domestic

3901D - Foreign

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  This notice will be sent when the program service center has been holding back retroactive benefits due to attorney involvement but has not received the attorney fee request within the 60-day time limit. It notifies the beneficiary that the retroactive check is being released, and that the attorney will still need approval from SSA for any fee charged.

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  Refer to NL 00703.005E for 3901 and 3901D text and fill-ins.

   

Fill-in:

1. (1) 

   amount of money withheld

Use Form SSA-L2000-C2 (Universal Notice) and follow notice standards. Information for this notice will be shown on Form SSA-573.