TN 17 (03-05)

Paragraph A: ATYR04;

Claimant/Auxiliary Notice – Partial Adjudication - Representative Eligible for Direct Payment

When a (1) wants to charge for helping with a Social Security claim, we must 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) in case we need to pay (5) (6).

We cannot tell you how much the (7) can charge at this time. When processing (8) claim we found we needed more information. To decide how much (9) benefits will be for (10), we need (11) (12) (13). When we get that information, we will decide the amount of (14) past-due benefits and send another letter telling you how much the (15) can charge. You can help us finish the work on (16) claim by taking the information to any Social Security office.

Fill-ins

1. always use representative

2. always use representative's

3. show the total fee amount withheld from all PICs/Show the single PICs fee amount withheld

4. the benefits due you and your family/your benefits

5. always use "the"

6. always use representative

7. always use representative

8. Ms. plus BLN (possessive)/ Mr. plus BLN (possessive) your

9. her/his/your

10. Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

11. Manual fill-in 1 which can include choices A or B

    1. proof of

    2. more information about

12. her/his/your

13. Manual fill-in 2 which can include choices of workers' compensation benefits/public disability benefits/workers' compensation and public disability benefits/military service/date of birth/or free format reason*

14. her/his/your

15. always use representative

16. her/his/your

Paragraph B: ATYR06; PCNATY002

Claimant/Auxiliary Notice – Partial Adjudication - Non-attorney Representative Ineligible for Direct Payment

When a representative wants to charge for helping with a Social Security claim, we must approve the fee.

We cannot tell you how much the representative can charge at this time. When processing (1) claim we found we needed more information. To decide how much (2) benefits will be for (3) , we need (4) (5) (6) . When we get that information, we will decide the amount of (7) past-due benefits and send another letter telling you how much the representative can charge. You can help us finish the work on (8) claim by taking the information to any Social Security office.

Fill-ins

1. Choice 1 - Ms. + BLN (possessive)
   Choice 2 - Mr. + BLN (possessive)
   Choice 3 - your

2. Choice 1 - her
   Choice 2 - his
   Choice 3 - your

3. Choice 1 - Month, year
   Choice 2 - Month, year and month, year
   Choice 3 - Month, year through month, year

4. Choice 1 - proof of
   Choice 2 - more information about

5. Choice 1 - her
   Choice 2 - his
   Choice 3 - your

6. Manual fill-in, e.g., worker's compensation benefits, state disability benefits, military service, date of birth

7. Choice 1 - her
   Choice 2 - his
   Choice 3 - your

8. Choice 1 - her
   Choice 2 - his
   Choice 3 - your

Paragraph C: ATYR21: Claimant Notice – ALJ or AAJ may have incorrectly approved fee agreement –Representative Eligible for Direct Payment

When a representative wants to charge for helping with a Social Security claim, we must approve the fee. We usually withhold 25 percent of past-due benefits in order to pay the approved representative's fee. We withheld $_(1)_ from _(2)_ in case we need to pay your representative.

When we decide the amount of the fee, we will let you and the representative know how much of this money will be used to pay the fee. We will send any remainder to _(3)_.

Fill-ins

1. The amount of past-due benefits withheld

2. Choice 1 – your past-due benefits
   Choice 2 – the past-due benefits due you and your family

3. Choice 1 – you

   Choice 2 – you and your family

Paragraph D: ATYR23: Auxiliary Notice (Auxiliary Not Living in the Same Household With Primary Claimant) – ALJ or AAJ may have incorrectly approved fee agreement - Representative Eligible for Direct Payment

When a representative wants to charge for helping with a Social Security claim, we must approve the fee. We usually withhold 25 percent of past-due benefits in order to pay the approved representative's fee. We withheld $_(1)_ from _(2)_ past-due benefits in case we need to pay _(3)_ representative.

When we decide the amount of the fee, we will let you and the representative know how much of this money will be used to pay the fee. We will send any remainder to you.

Fill-ins

1. The amount of past-due benefits withheld

2. Choice 1 – your
   Choice 2 – beneficiary's name (possessive case)

3. Number holder's name, first and last (possessive case)

Paragraph E: ATYR25: Claimant/Auxiliary Notice – ALJ or AAJ may have incorrectly approved fee agreement - Non-attorney Representative Ineligible for Direct Payment

When a representative wants to charge for helping with a Social Security claim, we must first approve the fee. When we decide the amount of the fee, we will let you and your representative know how much money he or she can charge you for the work on your claim.