Last Update: 9/9/04 (Transmittal I-1-47)
On (date of favorable determination on subsequent application) the Social Security Administration notified you that you are entitled to and/or eligible for (type of benefits to which claimant is entitled/eligible). Based on the information available to the decision maker at that time, SSA also approved the fee agreement between you and your representative, (representative's name), on the basis that the agreement met all the statutory conditions for approval and was not excepted from the fee agreement process.
I must rescind this approval and disapprove the fee agreement because
[Only include those that apply]
you and your representative(s) did not all sign the agreement.
the fee agreement sets a fee that is more than the lesser of 25 percent of the past-due benefits or $6,000.
considering the appointments of representative in the your applications dated (date of prior application) and (date of subsequent application),
you appointed more than one representative from a law firm or other business; all representatives did not sign a single fee agreement; and the representative(s) who did not sign the fee agreement, did not waive charging and collecting a fee.
you appointed representatives who are not members of the same law firm or other business, and the representative(s) from the other law firm(s) or business(s) did not waive charging and collecting a fee.
you discharged a representative or a representative withdrew from the case before I favorably decided the claim, and that representative did not waive charging and collecting a fee.
the representative died before I issued the favorable decision.
a State court has declared you legally incompetent and your legal guardian did not sign the agreement.
[other reason (e.g., did not receive written agreement before the date of the first favorable decision SSA made after the representative's involvement began).]
HOW TO ASK US TO REVIEW THE FEE AGREEMENT DETERMINATION
You or your representative may ask us to review the determination on the fee agreement. If you decide to ask us for a review, write us within 15 days from the day you get this order. Tell us that you disagree and give your reasons. Send your request to this address:
[If Administrative Law Judge (ALJ) disapproved fee agreement:
Name and address of Regional Chief ALJ who has jurisdiction over the claimant's servicing hearing office. Refer to the OCALJ staff listing for this information.
If Administrative Appeals Judge disapproved fee agreement:Social Security Administration
Your representative also has 15 days to write us if he or she does not agree with the determination on the fee agreement.
You should include the social security number(s) shown on this order on any papers that you send us.
AUTHORIZING A REPRESENTATIVE'S FEE UNDER THE FEE PETITION PROCESS
If neither you nor your representative requests review, your representative must file a fee petition if he or she wants to charge and collect a fee. I have enclosed with the representative's copy of this order a Form SSA-1560 (Petition to Obtain Approval of a Fee for Representing a Claimant before the Social Security Administration) (he/she) may use for this purpose.
(Name and title of ALJ or AAJ)