TN 7 (07-04)

Social Security Administration

Important Information

Program Service Center
Street Address
City, State ZIP
Date:
Claim/Case Number

Claimant's Name
Street Address
City, State ZIP

(Representative's Name) recently asked us to approve a fee of $(dollar amount) for representing you in your case before Social Security. We have enclosed a copy of this request.

Please let us know if you disagree with the fee requested or any information shown in the request. If you disagree, you must contact us within 20 days of receiving this letter. We will not address (Mr./Ms. representative's last name)’s request until after that time.

You may call us about this matter at (area code and phone number), or write to us using the enclosed self-addressed envelope. If you have questions about other Social Security matters, you may call us toll free at 1-800-772-1213, or call your local Social Security office at xxx-xxx-xxxx. We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

Street Address
City, State ZIP

If you do call or visit an office, please have this letter with you. It will help us answer your questions. This will help us serve you more quickly.

Assistant Regional Commissioner,
Processing Center Operations

Enclosures:

Fee Request
Self-addressed Envelope

cc:
Representative's Name