ADMINISTRATIVE HEARING RETAINER AGREEMENT

REPRESENTATION BEFORE ADMINISTRATIVE LAW JUDGE

AGREEMENT DATE: [__/__/____]

ATTORNEY INFORMATION

Name: [________________________________]
Bar Number: [________________________________]
Firm Name: [________________________________]
Address: [________________________________]
City, State, ZIP: [________________________________]
Telephone: [________________________________]
Email: [________________________________]

CLIENT INFORMATION

Name: [________________________________]
Address: [________________________________]
City, State, ZIP: [________________________________]
Telephone: [________________________________]
Email: [________________________________]
Social Security Number (last 4 digits, if required by agency): XXX-XX-[____]

ARTICLE 1: PURPOSE AND SCOPE OF REPRESENTATION

1.1 Limited Scope Acknowledgment

This Agreement establishes an attorney-client relationship for representation in administrative proceedings before an Administrative Law Judge (ALJ) or hearing officer. Client understands that this representation is LIMITED to the specific administrative matter and hearing described herein.

1.2 Administrative Matter Description

Agency: [________________________________]
Agency Office/Division: [________________________________]
Case/Claim Number: [________________________________]
Type of Proceeding:

☐ Social Security Disability (SSDI/SSI)
☐ Medicare/Medicaid Appeal
☐ Unemployment Insurance
☐ Workers' Compensation
☐ Professional License/Certification
☐ Environmental/EPA Proceeding
☐ OSHA/Workplace Safety
☐ Immigration (EOIR)
☐ Veterans Benefits (VA)
☐ Tax (IRS/State)
☐ Government Contract Dispute
☐ Public Benefits (SNAP, TANF, etc.)
☐ Civil Rights/EEOC
☐ Labor Relations (NLRB)
☐ Securities/Financial Regulation
☐ Other: [________________________________]

Brief Description of Matter:
[________________________________]
[________________________________]

Hearing Date (if scheduled): [__/__/____]
Hearing Location: [________________________________]
Assigned ALJ (if known): [________________________________]

1.3 Prior Proceeding History

☐ Initial determination/decision date: [__/__/____]
☐ Reconsideration/review level decision date: [__/__/____]
☐ Prior ALJ hearing date (if any): [__/__/____]
☐ Prior appeal level: [________________________________]

1.4 Services INCLUDED in This Agreement

Pre-Hearing Services:
☐ Review of agency file and prior decisions
☐ Review of evidence and documentation
☐ Development of hearing strategy
☐ Identification of additional evidence needed
☐ Subpoena preparation and issuance
☐ Witness identification and preparation
☐ Prehearing conference attendance
☐ Prehearing brief or position statement
☐ Objections to evidence or procedure
☐ Request for continuance (if needed)

Hearing Representation:
☐ Attendance at ALJ/administrative hearing
☐ Opening statement
☐ Direct examination of Client
☐ Direct examination of witnesses
☐ Cross-examination of agency witnesses
☐ Cross-examination of expert witnesses (vocational, medical, etc.)
☐ Introduction of documentary evidence
☐ Objections during hearing
☐ Closing argument or post-hearing brief

Post-Hearing Services (check those included):
☐ Post-hearing brief (due within [____] days of hearing)
☐ Response to agency's post-hearing submission
☐ Review of ALJ decision
☐ Explanation of decision to Client
☐ Advice regarding appeal options

1.5 Services EXCLUDED from This Agreement

Client understands and agrees that the following services are NOT included:

Prior Level Services:
☐ Initial application/claim filing
☐ Reconsideration/review level representation
☐ Gathering medical records or other evidence
☐ Obtaining expert reports or evaluations

Post-Hearing/Appeal Services:
☐ Appeal to agency review board/appeals council
☐ Federal court appeal
☐ State court appeal
☐ Remand proceedings (new agreement required)

Other Services:
☐ Representation in related civil or criminal matters
☐ Representation before other agencies
☐ Advice on matters beyond this specific claim
☐ Collection of benefits awarded
☐ Other: [________________________________]

CLIENT INITIALS: [____]

ARTICLE 2: AGENCY-SPECIFIC REQUIREMENTS

2.1 Appointment of Representative

Client agrees to execute the following agency forms to appoint Attorney as representative:

☐ SSA Form SSA-1696 (Appointment of Representative)
☐ VA Form 21-22a (Appointment of Individual as Claimant's Representative)
☐ DOL Form (specify): [________________________________]
☐ IRS Form 2848 (Power of Attorney and Declaration of Representative)
☐ USCIS Form G-28 (Notice of Entry of Appearance as Attorney)
☐ EEOC Designation of Representative
☐ State Agency Form: [________________________________]
☐ Other: [________________________________]

2.2 Fee Agreement Filing

☐ This Agreement or a separate fee agreement must be filed with the agency
☐ Agency fee approval required before payment to Attorney
☐ Fee is subject to agency fee schedule or cap
☐ No agency filing required

Agency Fee Limitations (if applicable):
[________________________________]

2.3 Direct Payment Authorization

☐ Client authorizes direct payment of attorney fees from past-due benefits (if applicable)
☐ Client will pay attorney fees directly; no withholding requested

ARTICLE 3: EVIDENCE AND DOCUMENTATION

3.1 Client Responsibilities

Client agrees to:

☐ Provide complete and accurate information regarding the claim
☐ Sign all necessary authorizations for release of records
☐ Identify all treating physicians, providers, and facilities
☐ Provide contact information for potential witnesses
☐ Notify Attorney of any new medical treatment or evidence
☐ Attend all scheduled appointments and examinations
☐ Appear at the hearing as scheduled

3.2 Evidence Development

Attorney will assist with the following:

☐ Requesting records from providers identified by Client
☐ Summarizing medical/documentary evidence
☐ Identifying gaps in evidence
☐ Recommending additional evaluations or evidence

Client is responsible for:

☐ Obtaining records from: [________________________________]
☐ Attending consultative examination if required by agency
☐ Obtaining supporting statements from: [________________________________]
☐ Costs of obtaining records and reports

3.3 Expert Witnesses

☐ No expert witnesses anticipated
☐ Medical expert may testify at hearing (agency-provided)
☐ Vocational expert may testify at hearing (agency-provided)
☐ Client authorizes Attorney to retain expert witness (separate cost)
- Type of expert: [________________________________]
- Estimated cost: $[________________________________]

ARTICLE 4: HEARING PROCEDURES

4.1 Hearing Format

☐ In-person hearing at: [________________________________]
☐ Telephone hearing
☐ Video teleconference (VTC) hearing
☐ On-the-record (documentary review only)
☐ Format to be determined by agency

4.2 Hearing Attendance

Attorney will attend the hearing and represent Client. Client MUST attend the hearing unless:

☐ Agency permits representative-only appearance
☐ Client is physically unable to attend (documentation required)
☐ Hearing is on-the-record only

Failure to Appear: Client understands that failure to appear at a scheduled hearing without good cause may result in dismissal of the claim.

4.3 Continuance Requests

If Client needs to request a continuance:

☐ Client must notify Attorney immediately
☐ Attorney will file continuance request with agency
☐ There is no guarantee the continuance will be granted
☐ Multiple continuances may negatively impact the case

ARTICLE 5: FEES AND PAYMENT

5.1 Fee Structure

Client agrees to pay Attorney according to the following structure:

For Social Security/SSI Cases:
☐ Contingent fee equal to [____]% of past-due benefits awarded, not to exceed the maximum fee permitted by SSA (currently $[________________________________])
☐ Fee petition will be filed for amounts exceeding the fee agreement cap

For Workers' Compensation Cases:
☐ Contingent fee equal to [____]% of benefits awarded
☐ Subject to approval by [________________________________]

For Other Administrative Matters:
☐ Flat Fee: $[________________________________]
- Covers hearing preparation and attendance
- Post-hearing brief additional: $[________________________________]

☐ Hourly Rate:
- Attorney rate: $[________________________________] per hour
- Paralegal rate: $[________________________________] per hour
- Estimated total hours: [____] to [____]

☐ Contingent Fee: [____]% of benefits/award recovered

☐ Hybrid Fee:
- Non-refundable engagement fee: $[________________________________]
- Plus [____]% of any award/benefits

5.2 Retainer Deposit

☐ No retainer required (contingent fee arrangement)
☐ Retainer deposit of $[________________________________] due upon execution
☐ Non-refundable engagement fee
☐ Refundable security retainer
☐ Advance on fees

5.3 Costs and Expenses

Client agrees to pay the following costs (regardless of outcome):

☐ Medical records request fees: estimated $[________________________________]
☐ Copying/document reproduction: $[____] per page
☐ Expert witness fees: estimated $[________________________________]
☐ Travel expenses for out-of-town hearing: estimated $[________________________________]
☐ Subpoena and service fees
☐ Transcript fees
☐ Other: [________________________________]

Cost Payment:
☐ Client will pay costs as incurred
☐ Costs will be advanced by Attorney and deducted from award
☐ Costs due regardless of outcome

5.4 Fee If Claim Is Denied

If the claim is denied at the ALJ level:

☐ Client owes only costs incurred (contingent fee arrangement)
☐ Client owes fees for services rendered
☐ Retainer is forfeited; no additional fees owed
☐ Other: [________________________________]

5.5 Fee If Claim Is Remanded

If the claim is remanded for further proceedings:

☐ This Agreement terminates; new agreement required
☐ This Agreement continues for remand proceedings
☐ Fee applies to final favorable decision, whenever obtained
☐ Other: [________________________________]

ARTICLE 6: APPEALS

6.1 Appeal Rights

Client understands that after an ALJ decision:

☐ There may be a right to appeal to an agency review board or appeals council
☐ There may be a right to appeal to federal or state court
☐ Appeal deadlines are strict and cannot be extended
☐ Attorney DOES NOT represent Client on appeal under this Agreement (unless specified below)

6.2 Appeal Services Under This Agreement

☐ Appeal services are NOT included in this Agreement
☐ Appeal services ARE included:
- Request for review by: [________________________________]
- Additional fee for appeal: $[________________________________]
- Same contingent fee applies to appeal

6.3 Appeal Deadline Notification

If the ALJ decision is unfavorable, Attorney will:

☐ Notify Client of appeal rights and deadlines
☐ Provide written explanation of appeal options
☐ Assist Client in finding appellate counsel if requested

CLIENT ACKNOWLEDGES: Attorney's representation ends after the ALJ decision unless appeal services are specifically included above. Client is responsible for meeting appeal deadlines.

CLIENT INITIALS: [____]

ARTICLE 7: COMMUNICATION

7.1 Client Contact Information

Client agrees to:

☐ Keep Attorney informed of current address and phone number
☐ Notify Attorney immediately of any address/phone changes
☐ Respond to Attorney communications within [____] business days
☐ Check mail and messages regularly for hearing notices

7.2 Attorney Communications

Attorney will communicate with Client regarding:

☐ Hearing date, time, and location
☐ Evidence received or needed
☐ Preparation requirements
☐ Hearing strategy
☐ Decision received and its meaning
☐ Appeal deadlines and options

7.3 Agency Communications

☐ Attorney will file notice of representation with agency
☐ Agency communications will be sent to Attorney
☐ Client should forward any agency correspondence received to Attorney immediately

ARTICLE 8: TERMINATION

8.1 Termination by Client

Client may terminate this Agreement at any time by providing written notice to Attorney. Upon termination:

☐ Client will notify agency of termination of representation
☐ Attorney will withdraw as representative
☐ Client will be responsible for fees earned and costs incurred
☐ If contingent fee, Attorney may file fee petition for services rendered

8.2 Termination by Attorney

Attorney may withdraw from representation upon:

☐ Client's failure to cooperate or provide required information
☐ Client's failure to attend scheduled appointments or hearing
☐ Client's failure to pay costs when due
☐ Discovery of conflict of interest
☐ Client's misrepresentation of material facts
☐ Other good cause

8.3 Substitution of Counsel

If Client wishes to retain different counsel:

☐ Client must provide written notice to Attorney
☐ Attorney will cooperate with transition to new counsel
☐ Attorney may retain lien for services rendered
☐ Fee division with successor counsel may apply

ARTICLE 9: DISCLAIMERS AND ACKNOWLEDGMENTS

9.1 No Guarantee of Outcome

Client acknowledges that Attorney has made NO promises or guarantees regarding the outcome of the administrative hearing. Results depend on evidence, law, and the ALJ's evaluation.

9.2 Agency Decision Authority

Client understands that:

☐ The ALJ has discretion in weighing evidence and credibility
☐ The agency's decision may differ from Attorney's assessment
☐ Favorable evidence does not guarantee a favorable decision
☐ Attorney cannot influence or predict the ALJ's decision

9.3 Benefits/Award Timing

If the claim is approved:

☐ There may be a delay before benefits are paid
☐ Attorney fees will be deducted before payment to Client (if applicable)
☐ Back benefits calculation may differ from estimates
☐ Ongoing benefits may be subject to review and adjustment

9.4 Limited Scope Understanding

CLIENT ACKNOWLEDGES AND UNDERSTANDS:

☐ This Agreement covers ONLY the administrative hearing level described
☐ Attorney is not representing Client in any other matter
☐ Client may need separate counsel for appeals or other proceedings
☐ Deadlines for appeals are strict and must be observed
☐ Attorney has explained the risks and limitations of this arrangement

CLIENT INITIALS: [____]

ARTICLE 10: GENERAL PROVISIONS

10.1 Entire Agreement

This Agreement constitutes the entire agreement between the parties regarding the subject matter hereof.

10.2 Amendments

This Agreement may only be amended by written instrument signed by both parties.

10.3 Governing Law

This Agreement shall be governed by the laws of the State of [________________________________] and applicable federal regulations.

10.4 Fee Disputes

Any dispute regarding attorney fees shall be resolved by:

☐ Agency fee adjudication process (if applicable)
☐ Bar association fee arbitration
☐ Mediation followed by arbitration
☐ Litigation

10.5 Severability

If any provision of this Agreement is found to be unenforceable, the remaining provisions shall continue in full force and effect.

ARTICLE 11: SIGNATURES

By signing below, the parties acknowledge that they have read, understand, and agree to be bound by the terms of this Agreement.

ATTORNEY:

Signature: [________________________________]
Name: [________________________________]
Date: [__/__/____]

CLIENT:

Signature: [________________________________]
Name: [________________________________]
Date: [__/__/____]

EXHIBIT A: AGENCY-SPECIFIC INFORMATION

Social Security Administration (if applicable)

Claim Type:
☐ Title II - Disability Insurance Benefits (DIB/SSDI)
☐ Title XVI - Supplemental Security Income (SSI)
☐ Both Title II and Title XVI

Alleged Onset Date: [__/__/____]
Date Last Insured (if applicable): [__/__/____]
Primary Disabling Conditions:
1. [________________________________]
2. [________________________________]
3. [________________________________]

Hearing Office: [________________________________]

Other Agency Information

Agency Contact:
Name: [________________________________]
Address: [________________________________]
Phone: [________________________________]
Email: [________________________________]

Key Deadlines:
- Prehearing submission deadline: [__/__/____]
- Document exchange deadline: [__/__/____]
- Other: [________________________________]

EXHIBIT B: EVIDENCE CHECKLIST

Medical Evidence:
☐ Treating physician records
☐ Hospital records
☐ Mental health treatment records
☐ Physical therapy records
☐ Consultative examination reports
☐ Medical expert opinions
☐ Prescription records
☐ Laboratory/diagnostic test results

Employment/Vocational Evidence:
☐ Work history report
☐ Employer statements
☐ Job descriptions
☐ Vocational expert report
☐ Earnings records

Other Evidence:
☐ Function report (activities of daily living)
☐ Third-party statements
☐ School records (if applicable)
☐ VA records (if applicable)
☐ Prior applications/decisions
☐ Other: [________________________________]

SOURCES AND REFERENCES

• 5 U.S.C. § 555(b) - Right to Counsel in Administrative Proceedings
• 20 C.F.R. § 404.1720 et seq. - SSA Representative Rules
• 42 C.F.R. Part 405, Subpart I - Medicare ALJ Hearings
• CMS Medicare Appeals Process Guidelines
• State Administrative Procedure Acts
• Agency-specific hearing procedures

This template is provided for informational purposes only and should be reviewed and customized by a licensed attorney familiar with the specific agency and type of administrative proceeding.