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GN 03940: Fee Authorization Under the Fee Agreement Process

Effective Dates: 01/26/1999 - Present

TN 10 (07-97)

Paragraph ATYR20

Fee Amount - Title II Claim Only - Number Holder (N/H) Only -Delayed Auxiliary Claim(s) Pending or Expected - N/H's Award Notice

Information About Representative's or Lawyer's Fees

We base the amount of your  (1)  fee on the total past-due benefits for you and your family. Your past-due benefits are $  (2)  for  (3)  . Under the fee agreement, your  (4)  can charge you $  (5)  for his or her work. As soon as we make a decision on your family's claim(s) and decide the amount of their past-due benefits, we will tell them if your  (6)  can charge an additional fee. We also will say how much that fee amount will be.

The amount of the fee for your and your family's claims does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and your  (7)  .

Fill-ins:

  1. Choice 1 - representative's

    Choice 2 - lawyer's

  2. The amount of the N/H's past-due benefits

  3. Choice 1 - Month/Year

    Choice 2 - Month/Year through Month/Year

  4. Choice 1 - representative

    Choice 2 - lawyer

  5. The amount of the fee based on N/H's past-due benefits

  6. Choice 1 - representative

    Choice 2 - lawyer

  7. Choice 1 - representative

    Choice 2 - lawyer

Paragraph ATYR22

Fee Amount - Title II Claim Only - N/H and Non-delayed Auxiliary Beneficiary(ies) - Delayed Auxiliary Claim(s) Pending or Expected - N/H's Award Notice

Information About Representative's or Lawyer's Fees

We base the amount of your  (1)  fee on the total past-due benefits for you and your family. Your past-due benefits are $  (2)  for  (3)  .  (4)  past-due benefits are $  (5)  for  (6)  . Under the fee agreement, your  (7)  can charge you and  (8)  $  (9)  for his or her work. As soon as we make a decision on your  (10)  and decide the amount of the past-due benefits, we will tell  (11)  if your  (12)  can charge an additional fee. We also will say how much that fee amount will be.

The amount of the fee for your and your family's claims does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and your  (13)  .

Fill-ins:

  1. Choice 1 - representative's

    Choice 2 - lawyer's

  2. The amount of the N/H's past-due benefits

  3. Choice 1 - Month/Year

    Choice 2 - Month/Year through Month/Year

  4. Choice 1 - [Current action involves only one auxiliary beneficiary] - Insert possessive case of name of auxiliary beneficiary in the format First Name, Last Name. Example: Henry James'

    Choice 2 - [When current action involves two or more auxiliary beneficiaries with same pay period] Insert - Your family's

  5. The amount of the non-delayed auxiliary beneficiary's(ies') past-due benefits

  6. Choice 1 - Month/Year

    Choice 2 - Month/Year through Month/Year

  7. Choice 1 - representative

    Choice 2 - lawyer

  8. Choice 1 - [Current action involves only one auxiliary beneficiary] - Insert name of auxiliary beneficiary in the format First Name, Last Name. Example: Henry James

    Choice 2 - [When current action involves two or more auxiliary beneficiaries with same pay period] Insert - your family

  9. The amount of the fee based on total past-due benefits for the N/H's claim and any non-delayed auxiliary claims

  10. Choice 1 - spouse's claim

    Choice 2 - other child's claim

    Choice 3 - other children's claims

    Choice 4 - spouse's and other child's claims

    Choice 5 - spouse's and other children's claims

  11. Choice 1 - him

    Choice 2 - her

    Choice 3 - them

  12. Choice 1 - representative

    Choice 2 - lawyer

  13. Choice 1 - representative

    Choice 2 - lawyer

Paragraph ATYR24

Fee Amount - Concurrent Titles II and XVI Claims Offset Information Pending - Delayed Auxiliary Claims(s) Pending or Expected -N/H's Award Notice

Information About Representative's or Lawyer's Fees

We base the amount of your  (1)  fee on the total past-due benefits for you and your family. Under the fee agreement, your  (2)  can charge you $  (3)  for his or her work. As soon as we make a decision on your family's claim(s) and decide the amount of their past-due benefits, we will tell them if your  (4)  can charge an additional fee. We also will say how much that fee amount will be.

The amount of the fee for your and your family's claims does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and your  (5)  .

Fill-ins:

  1. Choice 1 - representative's

    Choice 2 - lawyer's

  2. Choice 1 - representative

    Choice 2 - lawyer

  3. The amount of the fee based on N/H's past-due benefits

  4. Choice 1 - representative

    Choice 2 - lawyer

  5. Choice 1 - representative

    Choice 2 - lawyer

Paragraph ATYR26

Fee Amount - Concurrent Titles II and XVI Claims Offset Information Pending - N /H and Non-Delayed Auxiliary Beneficiary(ies) -Delayed Auxiliary Claims Pending or Expected - N/H's Award Notice

Information About Representative's or Lawyer's Fees

We base the amount of your  (1)  fee on the total past-due benefits for you and your family. Under the fee agreement, your  (2)  can charge you and  (3)  $  (4)  for his or her work. As soon as we make a decision on your  (5)  and decide the amount of the past-due benefits, we will tell  (6)  if your  (7)  can charge an additional fee. We also will say how much that fee amount will be.

The amount of the fee for your and your family's claims does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and your  (8)  .

Fill-ins:

  1. Choice 1 - representative's

    Choice 2 - lawyer's

  2. Choice 1 - representative

    Choice 2 - lawyer

  3. Choice 1 - [Current action involves only one auxiliary beneficiary] - Insert name of auxiliary beneficiary in the format First Name, Last Name. Example: Henry James

    Choice 2 - [When current action involves two or more auxiliary beneficiaries with same pay period] Insert- your family

  4. The amount of the fee based on the N/H's and any non-delayed auxiliary's(ies') past-due benefits

  5. Choice 1 - spouse's claim

    Choice 2 - other child's claim

    Choice 3 - other children's claims

    Choice 4 - spouse's and other child's claims

    Choice 5 - spouse's and other children's claims

    Choice 6 - family's claim

  6. Choice 1 - him

    Choice 2 - her

    Choice 3 - them

  7. Choice 1 - representative

    Choice 2 - lawyer

  8. Choice 1 - representative

    Choice 2 - lawyer

Previous:
GN 03930: Fee Authorization Under the Fee Petition Process
Up:
GN 039: Representation and Representative's Fee
Next:
GN 03950: Administrative Review of Fee Authorizations Under the Fee Petition Process
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