NL: Notices, Letters and Paragraphs
TN 70 (03-16)
Document Identifier for Word Processor: E3813
A. Exhibit Letter of notice to beneficiary in concurrent Title II and Title XVI cases where we applied Title II offset and there is a fee petition or fee agreement
|
G52 |
We are writing to give you new information about the (Comp. Gen.) benefits which (Comp. Gen.) on this Social Security record. |
|
Your Benefits |
|
(Refer to system-generated fill-ins in NL 00703.813B) |
|
|
3813A |
In an earlier letter, we told you we were withholding your Social Security benefits for (1). We did this because we thought we might have to reduce your Social Security benefits if you also received Supplemental Security Income (SSI) money for this period. |
Now we are writing to let you know that we cannot pay you (2) of the Social Security benefits we withheld. This is because you received SSI money for (3) . |
|
When you receive SSI money for a month, and later you receive Social Security benefits, we sometimes have to reduce your Social Security benefits. We do this to make sure that your total SSI and Social Security monthly payment is not more than it would have been if the Social Security benefits had been paid on time. |
|
|
Your past-due Social Security benefits are $ (4) for (5) . We usually withhold 25 percent of past-due benefits to pay a lawyer's fee. We withheld $ (6) from your past-due benefits to pay your lawyer. We are deducting (7) from the $ (8) in the benefits due for (9) . That leaves $ (10). |
|
What We Will Pay |
|
Allowing for your Social Security benefits, we should have paid you $ (11) less in SSI money. We have to take this out of the $ (12). |
|
Information About Lawyer's or Representative's Fees |
|
|
G16 |
(Refer to system-generated fill-ins in section B below) |
|
(Optional) |
If your lawyer wants to charge a fee for his or her services, he or she must ask us in writing to approve the amount of the fee. Your lawyer must give you a copy of his or her fee request and each attachment to the request. If your lawyer does not want to charge a fee, he or she should tell us. If your lawyer wants us to pay the fee from your withheld benefits, he or she should ask us to approve the fee within 60 days of the date of this letter. If your lawyer:
|
|
OR |
We told you in another letter that (1) lawyer could charge you no more than $ (2), under the fee agreement, for his or her work on your Social Security claim. We also explained your right to review the amount of the fee. |
Because no one asked us to review the amount of the fee, we are paying the lawyer $ (3) . This means we are paying the lawyer in full for the work on your Social Security claim. |
|
|
OR |
We have approved a fee of $ (1) to pay your lawyer for the work on your Social Security claim. We explained this fee, and your right to question it, in an earlier letter. |
We are sending your lawyer the fee from the money we withheld. This means we have paid your lawyer in full for the work done on your claim. |
|
|
OR |
We have approved a fee of $ (1) to pay your lawyer for the work on your Social Security claim. We explained this fee, and your right to question it, in an earlier letter. |
Your SSI Payments May Change |
|
We withheld $ (2) from your benefits, and we are sending this money to your lawyer. But this does not cover the entire fee. You and your lawyer will need to decide how to settle the additional $ (3) you owe. |
|
|
3816D |
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. |
G11 |
|
G20 |
|
|
C24 |
We are sending a copy of this letter to (1) . |
B. Instructions for a benefit authorizer (BA) or claims authorizer (CA) requesting the notice template
You request this notice in concurrent Title II and Title XVI cases when applying Title II offset. You should request an incomplete A22 notice. Once the MADCAP system performs the computations, it will generate certain captions and paragraphs for the notice. You can copy those paragraphs and finish the notice manually. Do not date and release this notice until we actually process the payment.
You can use this letter in:
fee petition cases where retroactive benefits exceed both the attorney fee and Title II offset,
fee agreement cases before we approve a fee,
fee petition cases after we approve and pay the fee,
fee agreement cases after we approve a fee but before we pay the fee,
concurrent cases where Title II offset does not apply because the retroactive Title II benefits exceeded the sum of the amount withheld for the attorney fee and the amount of Title II offset; and
cases where we have to contact the FO before applying Title II offset because the retroactive Title II benefits were less than the fee and offset amounts and the FO had to adjust the Title II income for the attorney fee.
The choice of paragraphs will depend on which of the above factors or combination of factors apply in all cases.
The system automatically generates paragraph G52 and the fill-ins.
You must type the caption “Your Benefits” and paragraph 3813A after paragraph G52 as shown in the text.
The system automatically generates the caption “What We Will Pay” and paragraph G16 with the fill-ins.
In fee petition cases,
if we have not previously sent E3814, include paragraph 3813B. (Paragraph 3813B will replace paragraph C18 or C19.)
if we are now paying the fee and the approved fee is less than or equal to 25 percent of past-due benefits, request 3813D.
if we are now paying the fee and the approved fee is more than 25 percent of past-due benefits, request 3813E.
In fee agreement cases,
if we are now paying the fee, request 3813C. (In some situations, we may have already paid the attorney fee.)
if we did not ask the FO to do a new computation after adjusting Title II income for the attorney fee, request 3816D.
The system automatically generates paragraphs, G11 and G20.
You must request a C24 paragraph. It is the last paragraph in the notice and will not have a caption.
Fill-ins:
|
3813A |
(1) |
month(s) and year(s) of withholding in “MM/YY” or “MM/YY through MM/YY” format |
(2) |
any, all |
|
|
(3) |
month(s) and year(s) of SSI payments in “MM/YY” or “MM/YY through MM/YY” format |
|
|
(4) |
past-due benefits for fee purposes (which may differ from prior month accrual) |
|
|
(5) |
month(s) and year(s) of past-due benefits period in “MM/YY” or “MM /YY through MM/YY” format |
|
|
(6) |
25 percent of past-due benefits |
|
|
(7) |
this amount (if approved fee equals 25 percent), or approved fee amount in “$$$$.¢¢” format (if approved fee does not equal 25 percent) |
|
|
(8) |
prior month accrual amount (total amount withheld pending SSI information) |
|
|
(9) |
month(s) and year(s) of withholding in “MM/YY” or “MM/YY through MM/YY” format (same as (1)) |
|
|
(10) |
prior month accrual minus amount subtracted for attorney fee |
|
(11) |
amount of SSI offset |
|
|
(12) |
prior month accrual minus amount subtracted for attorney fee (same as (10)) |
|
|
3813C |
(1) |
your (if NH), [NH's name, possessive] (if auxiliary) |
(2) |
fee amount |
|
(3) |
fee amount |
|
3813D |
(1) |
approved fee amount |
3813E |
(1) |
approved fee amount |
(2) |
25 percent of past-due benefits (same as fill-in (6) of 3813A) |
|
(3) |
amount of difference between fill-in (1) and (2) |
|
C24 |
(1) |
name of attorney |