I-1-2-103.Exhibit — Model Memorandum for ALJ/AAJ to Request Administrative Review of Fee Amount Based on an Approved Fee Agreement

Date:

Refer To:

To:

Regional Chief, Deputy Chief or Chief Administrative Law Judge

or

Deputy Chair or Designee, Appeals Council

Attorney Fee Branch, Office of Appellate Operations

Regarding:

___________, ____________________________________
Beneficiary Notice Control Number       Name of Claimant

From:

_______________________________________
_______________________________________

Subject:

Request for Administrative Review of Fee Based on an Approved Fee Agreement — ACTION

I approved the fee agreement between (Name of claimant) and their representative, (Name of representative).

I ask for a reduction of the fee that would otherwise result under the agreement. I believe there is evidence that shows that:

[Designate one]

• (Name of representative) did not represent the claimant's interests adequately.

• the fee is clearly excessive in light of the services provided.

My reasons follow. _______________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
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__________________________________           __________________
Signature                              Date