I-1-2-102.Exhibit — ALJ or AAJ Disapproves the Fee Agreement

I do not approve the fee agreement between you and your representative because:

[Only include those that apply]

• the Social Security Administration did not receive the written agreement before I decided the claim.

• you and your representative(s) did not all sign the agreement.

• the fee agreement sets a fee that is more than the lesser of 25 percent of the past-due benefits or $7,200.

• you appointed more than one representative from a law firm or other business; all representatives did not sign a single fee agreement; and the representative(s) who did not sign the fee agreement, did not waive charging and collecting a fee.

• you appointed representatives who are not members of the same law firm or other business, and the representative(s) from the other law firm(s) or business(s) did not waive charging and collecting a fee.

• you discharged a representative or a representative withdrew from the case before I favorably decided the claim, and that representative did not waive charging and collecting a fee.

• the representative died before I issued the favorable decision.

• a State court has declared you legally incompetent and your legal guardian did not sign the agreement.

• [other reason (e.g., did not receive written agreement before the date of the first favorable decision SSA made after the representative's involvement began).]

DO YOU DISAGREE WITH THE DETERMINATION?

You or your representative may 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 order. Tell us that you disagree and give your reasons. Send your request to this address:

[If Administrative Law Judge (ALJ) disapproved fee agreement:

Name and address of Regional Chief ALJ in region where case was heard.

If Administrative Appeals Judge disapproved fee agreement:

Social Security Administration
Office of Appellate Operations
Attn: Attorney Fee Branch
6401 Security Blvd
Baltimore, MD 21235-6401]

Your representative also has 15 days to write us if the representative does not agree with the determination on the fee.

You should include the social security number(s) shown on this order on any papers that you send us.

AUTHORIZING A REPRESENTATIVE'S FEE UNDER THE FEE PETITION PROCESS

If neither you nor your representative requests review, your representative must file a fee petition if the representative wants to charge and collect a fee. I have enclosed with the representative's copy of this order a Form SSA-1560 (Petition to Obtain Approval of a Fee for Representing a Claimant before the Social Security Administration) your representative may use for this purpose.

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