Fee For Services

My representative and I understand that, for a fee to be payable, the Social Security Administration (SSA) must approve any fee my representative charges or collects from me for services my representative provides in proceedings before SSA in connection with my claim(s) for benefits.

We agree that, if SSA favorably decides the claim(s), I will pay my representative a fee equal to the lesser of [Insert a number less than or equal to 25 percent] percent of the past-due benefits resulting from my claim(s) or [Insert a number less than or equal to the applicable specified dollar limit established pursuant to section 206(a)(2)(A) of the Social Security Act (e.g., $5,300, $6,000)].

Review of the Fee

We understand that one or both of us may request review of the fee amount, in writing, within 15 days after SSA has notified us of any amount my representative can charge.

  • My representative may ask SSA to increase the fee, and [Insert he or she ] has informed me that [Insert he or she] will do so if [Insert the conditions under which the representative might seek a fee higher than the fee otherwise agreed upon].

  • I may ask SSA to reduce the fee.

  • An affected auxiliary Social Security beneficiary, if any, may ask SSA to reduce the fee too.

  • Also, if SSA approved the fee agreement, the person(s) who decided my claim(s) may ask for a reduction of the fee under the agreement if, in his or her opinion, my representative did not represent my interests adequately or the fee is clearly excessive for the services provided.

If someone requests review, SSA generally would send the other(s) a copy and offer an opportunity to comment on the request and provide more information to the person reviewing the request. SSA then would finally decide the amount of the fee and notify us in writing whether the fee increased, decreased, or did not change.

We both have received signed copies of this agreement.