GN 03960: Administrative Review of Determinations Under the Fee Agreement Process
TN 3 (03-95)
MEMORANDUM TO |
: NE MAT SE GL WN MAM ODIO Processing Center |
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| REGARDING | : | . - - , | |
Account # & Symbol |
Name of Wage Earner or Beneficary |
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| FROM | : | ||
SUBJECT |
: |
Request for Administrative Review of Fee Based on an Approved Fee Agreement — ACTION |
|
I approved the fee agreement between
(Name of Claimant)
and .
(Name of Representative)
I ask for a reduction of the fee which would otherwise result under the agreement because, I believe, the evidence shows:
(Designate One)
/ / the fee is clearly excessive in light of the services provided
/ / did not represent the claimant's interest adequately.
Name of Representative
My reasons follow.
| Signature | Date |
Attachment(s) / / Yes / /No
| cc: | , Claimaint | |
| , Representative | ||
| , Auxiliary Beneficary(ies) | ||