NL: Notices, Letters and Paragraphs
TN 4 (08-12)
ATY016 DETERMINATION OF REPRESENTATIVE'S ASSESSMENT AMOUNT – NH, NH AND AUXILIARIES OR AUXILIARIES ONLY – SSA PAYING ONE REPRESENTATIVE, NO PREVIOUS ASSESSMENT (L34)
(Requested)
Caption: Information About Representative's Fees
We are paying the (1) from the benefits we withheld. Therefore, we must collect a service charge from him or her. The service charge is 6.3 percent of the fee amount we pay, but not more than $93.00, which is the most we can collect in each case under the law. We will subtract the service charge from the amount payable to the (2) . (3)
The (4) cannot ask you to pay for the service charge. If the (5) disagrees with the amount of the service charge, he or she must write to the address shown at the top of this letter. The (6) must tell us why he or she disagrees within 15 days from the day he or she gets this letter.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3) – Systems Generated
Choice 1: After we subtract the amount we are paying towards the fee, we will send you the balance of the amount withheld.
Choice 2: Null
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Systems Generated
Choice 1: representative
Fill-in (6) - Systems Generated
Choice 1: representative
ATY054 NO PAST-DUE BENEFITS AVAILABLE — REPRESENTATIVE INVOLVED (A56)
(Requested)
Caption: Information About Representative's Fees
When a representative wants to charge for helping with a Social Security claim, we must first approve the fee. We usually withhold 25 percent of past-due benefits in order to pay the approved representative's fee. However, there are no past-due benefits available to be paid to the representative.
If all work on this case for (1) and (2) family is finished, and (3) representative wants to charge a fee, a request to have it approved should be sent to us right away.
When the amount of the fee is decided, SSA is not involved in paying the fee.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
ATY055 COURT CASE ATTORNEY FEE WITHHOLDING NH ONLY (C15)
(Requested)
Caption: Information About Representative's Fees
(1) (2) may ask the court to approve a fee no larger than 25 percent of past due benefits. Past due benefits are those payable through (3) , the month before the court's decision. For this reason, we are withholding (4) .
After the court sets the fee, we will let (5) and the (6) know how much of this money will be used to pay the fee. We will send any remainder to (7) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3) - Requested As A Date In Format Shown Below MM/CCYY
Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of withholding
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (6) - Systems Generated
Choice 1: representative
Fill-in (7) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
ATY056 COURT CASE ATTORNEY FEE WITHHOLDING FROM NH AND FAMILY (C16)
(Requested)
Caption: Information About Representative's Fees
(1) (2) may ask the court to approve a fee no larger than 25 percent of past due benefits. Past due benefits are those payable to (3) and (4) family through (5) , the month before the court's decision. For this reason, we are withholding (6) .
After the court sets the fee, we will let (7) and the (8) know how much of this money will be used to pay the fee. We will send any remainder to (9) and (10) family.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3) – Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (6) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of withholding
Fill-in (7) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (8) - Systems Generated
Choice 1: representative
Fill-in (9) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (10) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
ATY057 NOTICE TO CLAIMANT WHERE A REPRESENTATIVE FEE HAS NOT YET BEEN AUTHORIZED (C18)
(Requested)
Caption: Information About Representative's Fees
When a (1) wants to charge for helping with a Social Security claim, we must first approve the fee. We usually withhold 25 percent of past due benefits in order to pay the approved (2) fee. We withheld (3) from (4) past due benefits in case we need to pay (5) (6) .
If all the work on this case for (7) and (8) family is finished, and (9) (10) wants to charge a fee, a request to have it approved should be sent to us right away.
If all work is not finished in this case, the (11) should let us know that a fee will be charged. This must be done within 60 days of the date of this letter.
If the (12) will not charge a fee, a statement saying so, signed and dated by the (13) , should be sent to us instead.
When the amount of the fee is decided, we will let (14) and the (15) know how much of this money will be used to pay the fee. We will send any remainder to (16) . If the approved fee is more than the money we have withheld, the Social Security Administration is not involved in paying the rest of the fee.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of withholding
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: representative
Fill-in (7) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (9) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (10) - Systems Generated
Choice 1: representative
Fill-in (11) - Systems Generated
Choice 1: representative
Fill-in (12) - Systems Generated
Choice 1: representative
Fill-in (13) - Systems Generated
Choice 1: representative
Fill-in (14) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (15) - Systems Generated
Choice 1: representative
Fill-in (16) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
ATY058 NOTICE TO CLAIMANT AND FAMILY WHERE ATTORNEY FEE HAS NOT YET BEEN AUTHORIZED (C19)
(Requested)
Caption: Information About Representative's Fees
When a (1) wants to charge for helping with a Social Security claim, we must first approve the fee. We usually withhold 25 percent of past due benefits in order to pay the approved (2) fee. We withheld (3) from the past due benefits of (4) and (5) family in case we need to pay (6) (7) .
If all the work on this case for (8) and (9) family is finished, and (10) (11) wants to charge a fee, a request to have it approved should be sent to us right away.
If all work is not finished in this case, the (12) should let us know that a fee will be charged. This must be done within 60 days of the date of this letter.
If the (13) will not charge a fee, a statement saying so, signed and dated by the (14) , should be sent to us instead.
When the amount of that fee is decided, we will let (15) and the (16) know how much of this money will be used to pay the fee. We will send any remainder to (17) and (18) family. If the approved fee is more than the money we have withheld, the Social Security Administration is not involved in paying the rest of the fee.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated
Choice 1: representative's
Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of withholding
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: Beneficiary name
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: representative
Fill-in (8) - Systems Generated
Choice 1: you
Choice 2: Beneficiary name
Fill-in (9) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (10) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (11) - Systems Generated
Choice 1: representative
Fill-in (12) - Systems Generated
Choice 1: representative
Fill-in (13) - Systems Generated
Choice 1: representative
Fill-in (14)
Fill-in (15) - Systems Generated
Choice 1: you
Choice 2: Beneficiary name
Fill-in (16) - Systems Generated
Choice 1: representative
Fill-in (17) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (18) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
ATY059 TITLE II/TITLE XVI REPRESENTATIVE FEE AGREEMENT – OFFSET INFORMATION PENDING – NH OR AUXILIARY (IES) (L12)
(Requested)
Caption: What We Will Pay
We are holding (1) Social Security benefits for (2) . We may have to reduce these benefits if (3) received Supplemental Security Income (SSI) for this period. We will not reduce (4) past-due benefits if (5) did not get SSI benefits for those months.
(6)
When we decide how much (7) due for this period, we will send (8) another letter.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Beneficiary name possessive
Full-in (2) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) - Requested As A One Position Alpha Character
Choice 1: (A) However, we will withhold part of any past-due benefits to pay the representative.
Choice 2: (B) Null
Fill-in (7) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (8) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
ATY060 SSI OFFSET INFORMATION PENDING CRITICAL CASE FEE AGREEMENT OR FEE PETITION CASE (L13)
(Requested)
Caption: What We Will Pay
Although we are sending (1) (2) of the money (3) due for past months, we are withholding (4) Social Security benefits for (5) . We may have to reduce these benefits if (6) received Supplemental Security Income (SSI) for this period. We will not reduce (7) past-due benefits if (8) did not get SSI benefits for those months. (9)
When we decide how much (10) due for this period, we will send (11) another letter.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Beneficiary name
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of payment
Fill-in (3) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/ CCYY through MM/ CCYY
Fill-in (6) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (7) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (9) - Requested As A One Position Alpha Character
Choice 1: (A) However, we will withhold part of any past-due benefits to pay your representative. Later in this letter, we will tell you more about the money we are withholding to pay your representative.
Choice 2: (B) However, we will withhold part of any past-due benefits to pay his representative. Later in this letter, we will tell him more about the money we are withholding to pay his representative.
Choice 3: (C) However, we will withhold part of any past-due benefits to pay her representative. Later in this letter, we will tell her more about the money we are withholding to pay her representative.
Choice 4: (D) Null
Fill-in (10) Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (11) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
ATY061 TITLE II OFFSET APPLIED – CONCURRENT TITLE II/TITLE XVI - FEE AGREEMENT OR FEE PETITION (L22)
(Requested)
Caption: Your Benefits
In an earlier letter, we told (1) that we were withholding (2) Social Security benefits for (3) . We did this because we thought we might have to reduce (4) Social Security benefits if (5) also received Supplemental Security Income (SSI) money for this period.
Now we are writing to let you know that we cannot pay (6) (7) of the Social Security benefits we withheld. This is because (8) received SSI money for (9) .
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.
(10) past-due Social Security benefits are (11) for (12) . We usually withhold 25 percent of past-due benefits to pay a (13) fee. We withheld (14) from (15) past-due benefits to pay the (16) . We are deducting (17) from the (18) in benefits due for (19) . That leaves (20) .
Allowing for (21) Social Security benefits, we should have paid (22) (23) less in SSI money. We have to take this out of the (24) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (7) - Requested As A One Position Alpha Character
Choice 1 (A): any
Choice 2 (B): all
Fill-in (8) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (9) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (10) - Systems Generated
Choice 1: Your
Choice 2: Beneficiary's Name possessive
Fill-in (11) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of past-due benefits
Fill-in (12) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (13) - Systems Generated
Choice 1: representative's
Fill-in (14) - Requested As A Money Amount In Format $$$$$.¢¢
Attorney fee from past-due benefits
Fill-in (15) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (16) - Systems Generated
Choice 1: representative
Fill-in (17) - Requested As A One Position Alpha Character Or As A Money Amount In Format $$$$$.¢¢
Choice 1: (A) this amount
Choice 2: actual money amount being deducted
Fill-in (18) - Requested As A Money Amount In Format $$$$$.¢¢
Total amount of past-due benefits
Fill-in (19) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (20) - Requested As A Money Amount In Format $$$$$.¢¢
Balance of past-due benefits
Fill-in (21) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (22) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (23) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of Title II benefits that should have been withheld from SSI benefits
Fill-in (24) (Same as Fill-in 20)
Balance of past-due benefits
ATY062 FEE AGREEMENT CASE – CONCURRENT TITLE II/TITLE XVI – REPRESENTATIVE FEE BEING PAID (L23)
(Requested)
Caption: Information About Representative's Fees
We told (1) in another letter that the (2) could charge (3) no more than (4) , under the fee agreement, for his or her work on (5) Social Security claim. We also said, (6) , the (7) , or the person who decided (8) case could ask us to review the amount of the fee.
We withheld (9) from (10) benefits to pay the (11) . We are sending the (12) this money. This means we are paying the (13) in full for the work on your Social Security claim.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2 ) - Systems Generated
Choice 1: representative
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (7) - Systems Generated
Choice 1: representative
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (9) - Requested As A Money Amount In Format $$$$$.¢¢
Amount withheld
Fill-in (10) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (11) - Systems Generated
Choice 1: representative
Fill-in (12) - Systems Generated
Choice 1: representative
Fill-in (13) - Systems Generated
Choice 1: representative
ATY063 FEE AGREEMENT CASE TITLE II/TITLE XVI FEE MAY CHANGE SSI BENEFITS (Use if FO was not requested to recompute) (L24)
(Requested)
Caption: Your SSI Payments May Change
Because we approved a fee in (1) Social Security claim, the amount of benefits we used in figuring (2) SSI payments may change. Contact (3) local Social Security office to see if we can pay (4) more SSI money.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
ATY064 ADDITIONAL FEE AMOUNT – SSI AWARDED – CONCURRENT TITLE II/TITLE XVI (L32)
(Requested)
Caption: Information About Representative's Fees
The (1) may be able to charge an additional amount for his or her work on (2) Supplemental Security Income (SSI) claim. (3) will get another letter, about SSI, telling (4) the additional fee amount, if any, the (5) can charge.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: the
Fill-in (3) - Systems Generated
Choice 1: You
Choice 2: Beneficiary's name
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: representative
ATY065 DETERMINATION OF REPRESENTATIVE'S ASSESSMENT AMOUNT – NH, NH AND AUXILIARIES OR AUXILIARIES ONLY – SSA PAYING TWO OR MORE REPRESENTATIVES SIMULTANEOUSLY, NO PREVIOUS ASSESSMENT (L35)
(Requested)
Caption: Information About Representative's Fees
We are paying the (1) from the benefits we withheld. Therefore, we must collect a service charge from each of them. The service charge is 6.3 percent of the fee amount we pay, but not more than $93, which is the most we can collect in each case under the law. When 6.3 percent of the combined payments exceeds $93, we divide the $93 service charge based on the individual fee amounts. We will subtract part of the service charge from the fee amount payable to each (2) . (3)
A (4) cannot ask (5) to pay for the service charge. If a (6) disagrees with the amount of the service charge, he or she must write to the address shown at the top of this letter. The (7) must tell us why he or she disagrees within 15 days from the day he or she gets this letter.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representatives
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1: (A) After we subtract the amount we are paying towards the fees, we will send you the balance of the amount we withheld.
Choice 2: (B) Null
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (6) - Systems Generated
Choice 1: representative
Fill-in (7) - Systems Generated
Choice 1: representative
ATY066 DETERMINATION OF REPRESENTATIVE'S ASSESSMENT AMOUNT – NH, NH AND AUXILIARIES OR AUXILIARIES ONLY – SUBSEQUENT PAYMENT, SSA PREVIOUSLY ASSESSED LESS THAN $93 (L36)
(Requested)
Caption: Information About Representative's Fees
We are paying the (1) from the benefits we withheld. Therefore, we must collect a service charge from him or her. The service charge is 6.3 percent of the fee amount we pay, but not more than $93, which is the most we can collect in each case under the law. We previously paid a fee and collected (2) . The service charge we must collect now is (3) . We will subtract this service charge from the amount payable to the (4) . (5) The (6) cannot ask (7) to pay for the service charge. If the (8) disagrees with the amount of the service charge, he or she must write to the address shown at the top of this letter. The (9) must tell us why he or she disagrees within 15 days from the day he or she gets this letter.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Amount (assessment collected before)
Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
Amount (assessment being collected now)
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Requested As A One Position Alpha Character
Choice 1: (A) After we subtract the amount we are paying towards the fee, we will send you the balance of the amount withheld.
Choice 2: (B) NULL
Fill-in (6) - Systems Generated
Choice 1: representative
Fill-in (7) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (8) - Systems Generated
Choice 1: representative
Fill-in (9) - Systems Generated
Choice 1: representative
ATY067 Appointed Representation Data and Fee Established Appointed Representation Data (L38)
(Requested)
Caption: Information About Representative's Fees
If a representative, who is a (1) , registers with us to receive direct fee payment, because of the law we usually withhold part of the past-due benefits to pay the fee we approve. Although (2) representative is a (3) , he or she did not register for direct payment before we completed our work on (4) claim. For that reason, we did not withhold from (5) past-due benefits to pay the fee we approve. Therefore, the Social Security Administration is not involved in paying the fee. This is a matter between (6) and (7) (8) .
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) lawyer
Choice 2: (B) participant in the non-attorney direct payment demonstration project
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (3) - Systems Generated
Choice 1: lawyer
Choice 2: participant in the demonstration project
Fill-in (4) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (5) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (6) - Systems Generated
Choice 1: him
Choice 2 : her
Choice 3: you
Fill-in (7) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (8) - Systems Generated
Choice 1: representative
ATY068 REPRESENTATIVE FEE AGREEMENT – TITLE II/TITLE XVI – SSA WITHHOLDING PAST-DUE BENEFITS – NH (L14)
(Requested)
Caption: Information About Past-Due Benefits Withheld To Pay A Representative
(1) past-due Social Security benefits are (2) for (3) . Because of the law, we usually withhold 25 percent of the total past-due benefits or the maximum payable under the fee agreement to pay an approved (4) fee. We withheld (5) from (6) past-due benefits to pay the (7) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: representative
ATY069 FEE AGREEMENT AMOUNT – TITLE II/TITLE XVI – OFFSET INFORMATION PENDING (L15)
(Requested)
Caption: Information About Representative's Fees
Under the fee agreement, the (1) can charge (2) no more than (3) for his or her work on (4) Social Security claim. The amount of the fee does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between (5) and the (6) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢ Amount
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: representative
ATY070 FEE AMOUNT – CONCURRENT TITLE II AND TITLE XVI CLAIMS – OFFSET INFORMATION PENDING – NH ONLY (L27)
(Requested)
Caption: Information About Representative's Fees
We base the amount of the (1) fee on the total past-due benefits for (2) and (3) family. Under the fee agreement, the (4) can charge (5) (6) for his or her work. As soon as we make a decision on (7) family's claims and decide the amount of their past-due benefits, we will tell them if the (8) can charge an additional fee. We also will say how much that fee amount will be.
The amount of the fee for (9) and (10) family's claims does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between (11) and the (12) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative's
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of the fee
Fill-in (7) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) - Systems Generated
Choice 1: representative
Fill-in (9) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (10) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (11) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (12) - Systems Generated
Choice 1: representative
ATY071 DETERMINATION OF REPRESENTATIVE'S ASSESSMENT AMOUNT – NH, NH AND AUXILIARIES OR AUXILIARIES ONLY – SSA PREVIOUSLY ASSESSED MAXIMUM (L37)
(Requested)
Caption: Information About Representative's Fees
We are paying the (1) from the benefits we withheld. We usually collect a service charge of 6.3 percent of the fee amount we pay, but not more than $93, which is the most we can collect in each case under the law. Because we paid a fee and collected the full amount before, there is no additional charge. (2)
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: (A) representative
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) After we subtract the amount we are paying towards the fee, we will send you the balance of the amount we withheld.
Choice 1: (B) NULL
ATY800 FEE AGREEMENT APPROVED NUMBER HOLDER (L01)
(Requested)
Caption: Information About Representative's Fees
We have approved the fee agreement between you and your (1) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
ATY801 FEE AGREEMENT APPROVED AUXILIARY (L02)
(Requested)
Caption: Information About Representative's Fees
When (1) filed (2) claim for benefits, (3) used a (4) to help with the claim. We have approved a fee agreement between (5) and (6) (7) . The (8) work involved the benefits of everyone on the record.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Fill-in (3) - Systems Generated
Choice 1: he
Choice 2: she
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Systems Generated
Choice 1: Beneficiary's Name
Fill-in (6) - Systems Generated
Choice 1: the
Fill-in (7): - Systems Generated
Choice 1: representative
Fill-in (8) - Systems Generated
Choice 1: representative's
ATY804 FEE AGREEMENT AMOUNT NUMBER HOLDER TITLE II CLAIM ONLY (L03)
(Requested)
Caption: Information About Representative's Fees
(1) past-due benefits are (2) for (3) . Under the fee agreement, the (4) cannot charge you more than (5) for his or her work. The amount of the fee 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 the (6) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: Your
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: past due benefits
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY and MM/CCYY
Choice 3: MM/CCYY through MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: pending fee amount
Fill-in (6) - Systems Generated
Choice 1: representative
ATY808 FEE REVIEW PROCEDURE NUMBER HOLDER (L06)
(Requested)
Caption: How To Ask Us To Review The Fee
You, the (1) or the person who decided your case can ask us to review the amount of the fee we say the (2) can charge. (3)
If you think the amount of the fee is too high, write us within 15 days from the day you get this letter. Tell us that you disagree with the amount of the fee and give your reasons. Send your request to this address:
Social Security Administration
Office of Disability Adjudication and Review
Attorney Fee Branch
5107 Leesburg Pike
Falls Church, Virginia 22041-3255
The (4) also has 15 days to write us if he or she thinks the amount of the fee is too low. (5)
If we do not hear from you or the (6) we will assume you both agree with the amount of the fee shown.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1: (A) Your family members who have filed claims on your Social Security number (SSN) also may ask us to review the amount of the fee.
Choice 2: (B) null
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Systems Generated
Choice 1: null
Choice 2: null
Fill-in (6) - Systems Generated
Choice 1: representative
ATY809 FEE REVIEW PROCEDURE AUXILIARY USED ONLY WHEN AUXILIARY PAID AT DIFFERENT TIMETHAN N/H OR LIVING IN SEPARATE HOUSEHOLD (L07)
(Requested)
Caption: How To Ask Us To Review The Fee
You, (1) , the (2) or the person who decided your case can ask us to review the amount of the fee we say the (3) can charge.
If you think the amount of the fee is too high, write us within 15 days from the day you get this letter. Tell us that you disagree with the amount of the fee and give your reasons. Send your request to this address:
Social Security Administration
Office of Disability Adjudication and Review
Attorney Fee Branch
5107 Leesburg Pike
Falls Church, Virginia 22041-3255
The (4) also has 15 days to write us if he or she thinks the amount of the fee is too low. (5)
If we do not hear from you or the (6) , we will assume you both agree with the amount of the fee shown.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3) - Systems Generated
Choice 1: representative
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Systems Generated
Choice 1: null
Fill-in (6) - Systems Generated
Choice 1: representative
ATY816 NH FEE AGREEMENT DISAPPROVED NH REPRESENTED BY A REPRESENTATIVE. CAN ALSO BE USED WITH L14 OR L21 IN SSI/FEE PETITION CASE (L20)
(Requested)
Caption: Information About Representative's Fees
If your (1) wants us to pay the fee from your withheld benefits, he or she must ask us to approve the fee within 60 days of the date of this letter.
If your (2) :
Is finished working on this case and wants to charge a fee, he or she must tell us to approve the amount of the fee right away.
Is not finished working on this case and wants to charge a fee, he or she must tell us within 60 days of the date of this letter that he or she will ask for a fee.
Does not want to charge a fee or does not want us to pay the fee from the benefits we withheld, he or she should tell us right away.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated:
Choice 1: representative
ATY817 REVIEW OF THE DISAPPROVED FEE AGREEMENT – NH (L18)
(Requested)
Caption: How To Ask Us To Review The Determination On The Fee Agreement
You or the (1) can 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 letter. Tell us that you disagree and give your reasons. Send your request to this address:
Social Security Administration
Office of Disability Adjudication and Review
Attorney Fee Branch
5107 Leesburg Pike
Falls Church, Virginia 22041-3255
The (2) also has 15 days to write us if he or she does not agree with the determination on the fee agreement.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated
Choice 1: representative
ATY825 FEE AGREEMENT AMOUNT CONCURRENT TITLE II/TITLE XVI ADDITIONAL FEE FOR TITLE XVI CLAIM NUMBER HOLDER ONLY USE IN INITIALAWARDS/POSTENTITLEMENT/CESSATION CASES (L31)
(Requested)
Caption: Information About Representative's Fees
If we approve your claim for SSI, the (1) may be able to charge an additional amount for his or her work. We will send you another letter about SSI telling you the additional amount of the fee, if any, he or she can charge.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
ATY834 FEE AGREEMENT AMOUNT NH AND AUXILIARIES TITLE II CLAIM ONLY (L04)
(Requested)
Caption: Information About Representative's Fees
(1) past-due benefits are (2) for (3) . (4) family's past-due benefits are (5) for (6) . Under the fee agreement, the (7) cannot charge (8) and (9) family more than (10) for his or her work. The amount of the fee 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 the (11) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Full name possessive
Choice 2: Your
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: money amount
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: Your
Choice 2: Her
Choice 3: His
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: money amount
Fill-in (6) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (7) - Systems Generated
Choice 1: representative
Fill-in (8) - Systems Generated
Choice 1: Beneficiary's Name
Choice 2: you
Fill-in (9) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (10) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: pending fee amount
Fill-in (11) - Systems Generated
Choice 1: representative
ATY836 REPRESENTATIVE INVOLVED – SSA WITHHOLDING PAST DUE BENEFITS – NH (L09)
(Requested)
Caption: Information About Past-Due Benefits Withheld To Pay A Lawyer
Based on the law, we must withhold part of past-due benefits to pay an appointed representative. We cannot withhold more than 25 percent of past-due benefits to pay an authorized fee. We withheld (1) from (2) past-due benefits to pay (3) representative.
Fill-in values:
Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Mr. Beneficiary's Name possessive
Choice 2: Ms. Beneficiary's Name possessive
Choice 3: Beneficiary's First Name possessive
Choice 4: Beneficiary's Name possessive
Choice 5: your
Fill-in (3) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Choice 4: Beneficiary's Name possessive
Choice 5: the
ATY838 REPRESENTATIVE FEE AGREEMENT – TITLE II/TITLE XVI SSA WITHHOLDING PAST DUE BENEFITS – N/H AND AUXILIARIES (L21)
(Requested)
Caption: Information About Past-Due Benefits Withheld To Pay A Lawyer
Because of the law, we usually withhold 25 percent of the total past-due benefits to pay an approved (1) fee.
We withheld (2) from (3) past-due benefits to pay (4) (5) . We also withheld (6) from (7) family's past-due benefits. We base the amount of the fee (8) (9) can charge on the total past-due benefits due (10) and (11) family.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative's
Fill-in (2) - Systems Generated
Representative Fee Amount
Fill-in (3) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (4) - Systems Generated
Choice 1: the
Fill-in (5) - Systems Generated
Choice 1: representative
Fill-in (6) - Systems Generated
Choice 1: Amount
Fill-in (7) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (8) - Systems Generated
Choice 1: the
Fill-in (9) - Systems Generated
Choice 1: representative
Fill-in (10) - Systems Generated
Choice 1: Beneficiary Name
Choice 2: you
Fill-in (11) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
ATYR02 FEE AMOUNT UNKNOWN-NH PAST-DUE BENEFITS UNKNOWN OR AUXILIARY (IES) CLAIM PENDING (L08)
(Requested)
Caption: Information About Representative's Fees
We base the amount of (1) fee on past-due benefits, if any. As soon as we (2) determine the amount of past-due benefits, we will tell you the amount of the fee (3) can charge.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your representative's
Choice 2: the representative's
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) make a decision on your spouse's claim and
Choice 2: (B) make a decision on your family's claims and
Choice 3: (C) make a decision on your child's claim and
Choice 4: (D) make a decision on your children's claim and
Choice 5: (E) Null
Fill-in (3) - Systems Generated
Choice 1: your representative
Choice 2: the representative
ATYR03 FEE AGREEMENT SUBSEQUENTLY DISAPPROVED – NO PAST DUE BENEFITS – NH – TITLE II ONLY (L29)
(Requested)
Caption Information About Representative's Fees
We wrote you before and said we had approved the fee agreement between (1) and the (2) . We also said we would tell (3) and the (4) the amount of the fee he or she can charge (5) .
We base the fee amount we allow under a fee agreement on (6) past-due benefits. There are no past-due benefits. Therefore, we no longer approve the fee agreement between (7) and the (8) .
Even though we no longer approve the fee agreement, the (9) can still charge a fee for his or her services. If the (10) wants to charge a fee, he or she must ask us in writing to approve the fee. The (11) must give (12) a copy of his or her fee request and each attachment to the request. If the (13) does not want to charge a fee, he or she should tell us.
Fill-in values:
Fill-in (1) - Requested As A Language
Choice 1: Name of Beneficiary who hired the attorney or representative
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3 - Systems Generated
Choice 1: Ms. + Beneficiary's Last Name
Choice 2: Mr. + Beneficiary's Last Name
Choice 3: Beneficiary's First Name
Choice 4: Beneficiary's Name
Choice 5: you
Fill-in (4 - Systems Generated
Choice 1: representative
Fill-in (5 - Systems Generated
Choice 1: Ms. + Beneficiary's Last Name
Choice 2: Mr. + Beneficiary's Last Name
Choice 3: Beneficiary's First Name
Choice 4: Beneficiary's Name
Choice 5: you
Fill-in (6) - Systems Generated
Choice 1: her
Choice 2: his
Choice 3: your
Fill-in (7) - Systems Generated
Choice 1: her
Choice 2: him
Choice 3: you
Fill-in (8) - Systems Generated
Choice 1: representative
Fill-in (9) - Systems Generated
Choice 1: representative
Fill-in (10) - Systems Generated
Choice 1: representative
Fill-in (11) - Systems Generated
Choice 1: representative
Fill-in (12) - Systems Generated
Choice 1: her
Choice 2: him
Choice 3: you
Fill-in (13) - Systems Generated
Choice 1: representative
ATYR05 FEE AGREEMENT AMOUNT AUXILIARY TITLE II CLAIM ONLY -USED ONLY WHEN AUXILIARY PAID AT DIFFERENT TIME THAN N/H OR LIVING IN SEPARATE HOUSEHOLD (L16)
(Requested)
Caption: Information About Representative's Fees
(1) past-due benefits are (2) for (3) . Under the fee agreement between (4) and the (5) , the (6) cannot charge more than (7) for his or her work.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Full name possessive
Fill-in (2) - Systems Generated
Choice 1: amount
Fill-in (3) - Systems Generated
Choice 1: month and year
Choice 2: month and year through month and year
Fill-in (4) - Requested As A Language
Choice 1: Beneficiary's Name
Fill-in (5) - Systems Generated
Choice 1: representative
Fill-in (6) - Systems Generated
Choice 1: representative
Fill-in (7) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: money amount
ATYR12 REPRESENTATIVE INVOLVED – SSA WITHHOLDING PAST-DUE BENEFITS – AUXILIARY (IES) (L11)
(Requested)
Caption: Information About Past-Due Benefits Withheld To Pay A Representative
Because of the law, we usually withhold 25 percent of the total past-due benefits to pay an approved (1) fee. We withheld (2) from (3) past-due benefits to pay (4) (5) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative's
Fill-in (2) - Systems Generated
Choice 1: (Amount)
Fill-in (3) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (4) - Systems Generated
Choice 1: the
Fill-in (5) - Systems Generated
Choice 1: representative
ATYR15 FEE AGREEMENT NOT APPROVED – NH (L19)
(Requested)
Caption: Information About Representative's Fees
We cannot approve the fee agreement between you and your (1) because (2)
Even though we cannot approve the fee agreement, your (3) can still charge you a fee for his or her services. If your (4) wants to charge a fee, he or she must ask us in writing to approve the amount of the fee. Your (5) must give you a copy of his or her fee request and each attachment to the request. If your (6) does not want to charge a fee, he or she should tell us.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) we did not get a written agreement before we decided your claim.
Choice 2: (B) both you and your (representative) did not sign the agreement.
Choice 3: (C) it sets a fee amount that is more than 25 percent of past- due benefits or $6000.00.
Choice 4: (D) there are no past-due benefits. We base the fee amount we allow under a fee agreement on your past-due benefits. Since we do not owe you any past-due benefits, we cannot approve the fee agreement.
Choice 5: (E) you appointed more than one representative from a law firm or other business, and all representatives did not sign a single fee agreement (unless the representative(s) who did not sign waived any fee in your case).
Choice 6: (F) you appointed representatives who are not members of the same law firm or other business (unless the representative(s) from the other law firm or business waived any fee in your case).
Choice 7: (G) you discharged a representative, or a representative withdrew from the case, before we favorably decided the claim (unless the former representative waived any fee in your case).
Choice 8: (H) your representative died before we issued the favorable decision.
Choice 9: (I) you were declared legally incompetent by a State court and your guardian did not sign the fee agreement.
Fill-in (3) - Systems Generated
Choice 1: representative
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Systems Generated
Choice 1: representative
Fill-in (6) - Systems Generated
Choice 1: representative
ATYR20 FEE AMOUNT – TITLE II CLAIM ONLY – NH ONLY – DELAYED AUXILIARY CLAIM(S) PENDING OR EXPECTED – NH'S AWARD NOTICE (L25)
(Requested)
Caption: Information About Representative's Fees
We base the amount of the (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, the (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 the (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 claim(s) 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 the (7) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative's
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: PDB
Choice 2: PMA
Fill-in (3) - Systems Generated
Choice 1: DOEC in the format Month CCYY
Choice 2: DOES through LAST-WITHHOLDING-DATE in the format Month CCYY and Month CCYY
Choice 3: the period from DOEC through LAST-WITHHOLDING- DATE in the format Month CCYY through Month CCYY
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Pending-Fee-Agreement-Amount
Fill-in (6) - Systems Generated
Choice 1: representative
Fill-in (7) - Systems Generated
Choice 1: representative
ATYR22 FEE AMOUNT – CONCURRENT TITLE II AND TITLE XVI CLAIMS – OFFSET INFORMATION PENDING – NH AND NON-DELAYED AUXILIARY BENEFICIARY(IES) – DELAYED AUXILIARY CLAIMS PENDING OR EXPECTED – NH'S AWARD NOTICE(L26)
(Requested)
Caption: Information About Representative's Fees
We base the amount of the (1) fee on the total past-due benefits for you and your family. Your past-due benefits are (2) for (3) . (4) past-due benefits are (5) for (6) . Under the fee agreement, the (7) can charge you and (8) (9) for his or her work. As soon as we make a decision on your (10) and decide the amount of the past-due benefits, we will tell (11) if the (12) can charge an additional fee. We also will say how much that fee amount will be.
The amount of the fee for your and your family's claim(s) does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and the (13) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative's
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: sum of number holder's PMA and LPDA
Choice 2: number holder's PMA
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: DOEC in the format MONTH CCYY
Choice 2: DOEC through LAST-WITHHOLDING-DATE in the format MONTH CCYY and MONTH CCYY
Choice 3: the period from DOEC through LAST_WITHHOLDING- DATE in the format MONTH CCYY through MONTH CCYY
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1: (A) Beneficiary's Name, possessive
Choice 2: (B) Your family's
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Money Amount
Fill-in (6) - Systems Generated
Choice 1: DOEC in the format MONTH CCYY
Choice 2: DOEC through LAST-WITHHOLDING-DATE in the format MONTH CCYY and MONTH CCYY
Choice 3: the period from DOEC through LAST-WITHHOLDING- DATE in the format MONTH CCYY through MONTH CCYY
Fill-in (7) - Systems Generated
Choice 1: representative
Fill-in (8) - Systems Generated
Choice 1: Beneficiary's Name, possessive
Choice 2: your family
Fill-in (9) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Money Amount
Fill-in (10) - Requested As A One Position Alpha Character
Choice 1: (A) spouse's claim
Choice 2: (B) other child's claim
Choice 3: (C) other children's claims
Choice 4: (D) spouse's and other child's claims
Choice 5: (E) spouse's and other children's claims
Fill-in (11) - Systems Generated
Choice 1: him
Choice 2: her
Choice 3: them
Fill-in (12) - Systems Generated
Choice 1: representative
Fill-in (13) - Systems Generated
Choice 1: representative