TN 70 (03-16)

Document Identifier for Word Processor: E3816

A. Exhibit letter of notice explaining disposition of withheld retroactive benefits

We are writing to tell you that we have approved a fee of $ (1) to pay your representative for the work on your Social Security claim. We explained this fee, and your right to question it, in an earlier letter.

What We Will Pay Your Representative

Insert one of the following optional paragraphs:

3816 A  (approved fee exactly equals withheld benefits):

We withheld $ (1) from your benefits to pay your legal expenses. Since we have approved the fee, we are sending your representative this money. This means we have paid your representative in full for the work done on your claim.

If we issued your decision after January 31, 2000, we must charge your representative the maximum user fee or 6.3 percent of the amount we pay him or her from your past-due benefits. Your representative cannot charge or collect this expense from you. We will subtract the charge from the amount payable to the representative and send him or her the remainder. If your representative disagrees with this charge, he or she may write to the address on this letter; and tell us why he or she disagrees.

We are sending a copy of this letter to your representative.

3816 B (approved fee is less than withheld benefits):

We withheld $ (1) from your benefits to pay your legal expenses. We will send $ (2) of this money to your representative. This means we have paid your representative in full for the work on your claim. We will send the balance of $ (3) to you. You should receive this check soon.

If we issued your decision after January 31, 2000, we must charge your representative the maximum user fee or 6.3 percent of the amount we pay him or her from your past-due benefits. Your representative cannot charge or collect this expense from you. We will subtract the charge from the amount payable to the representative and send him or her the remainder. If your representative disagrees with this charge, he or she may write to the address on this letter; and tell us why he or she disagrees.

We are sending a copy of this letter to your representative.

3816 C  (approved fee is more than withheld benefits):

We withheld $ (1) from your benefits, and we are sending this money to your representative. But this does not cover the entire fee. You and your representative will need to decide how to settle the additional $ (2) you owe.

If we issued your decision after January 31, 2000, we must charge your representative the maximum user fee or 6.3 percent of the amount we pay him or her from your past-due benefits. Your representative cannot charge or collect this expense from you. We will subtract the charge from the amount payable to the representative and send him or her the remainder. If your representative disagrees with this charge, he or she may write to the address on this letter; and tell us why he or she disagrees.

We are sending a copy of this letter to your representative.

3816 D  (concurrent Title II and Title XVI case subject to windfall offset)

Your SSI Payments May Change

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.

If You Have Any Questions

3901C - Domestic

3901D - Foreign

B. Instructions for sending and releasing the notice

Send this notice to the claimant after the program service center or Office of Hearings Operations (OHO) reviews and approves the attorney's fee request. The notice will contain one of three optional paragraphs explaining the disposition of any retroactive benefits we withheld. It will also contain paragraph 3816D if this is a concurrent Title II and Title XVI cases subject to windfall offset. Do not date and release this notice until we actually process the payment.

Send a copy of the notice to OHO when one of the following conditions is present:

1. Reconsideration reviewer requests it.

2. The salmon copy of the HA-505 Transmittal Form is in file.

3. The HA-L48 (Transmittal by Office of Hearings Operations (OHO) ) is in file and no one lined-out OHO involvement.

For 3901C and 3901D text and fill-ins refer to NL 00703.005E.

Fill-ins:

1. amount of approved fee

3816A

1. amount withheld

3816B

1. amount withheld

2. amount of approved fee

3. amount of difference between approved fee and benefits withheld

3816C

1. amount withheld

2. amount of difference between approved fee and benefits withheld

3816D

1. you OR beneficiary’s name

2. your OR his OR her

3. your OR his OR her

4. you OR him OR her

C. Typing instructions for manual notices

Use your designated notice system for manual notice entry and follow notice standards. You can also use Form SSA-573 (Special Typing Instructions) for typing instructions to the Benefit Authorizer (BA).