SSA REPRESENTATIVE FEE AGREEMENT

PARTIES TO AGREEMENT

Claimant Information:
- Full Legal Name: _________________________________________________
- Social Security Number: _____ - _____ - _________
- Date of Birth: ____________________
- Current Address: _________________________________________________
- Phone Number: _________________________________________________
- Email Address: _________________________________________________

Representative Information:
- Name: _________________________________________________
- Firm Name: _________________________________________________
- Address: _________________________________________________
- Phone: _________________ Fax: _________________
- Email: _________________________________________________
- State Bar Number: _________________________________________________
- SSA Representative ID (if applicable): _________________________________________________

TYPE OF FEE AGREEMENT

☐ Fee Agreement Process (42 U.S.C. § 406(a)(2)(A))
- Subject to SSA approval
- Maximum fee: Lesser of 25% of past-due benefits or statutory cap
- Current statutory cap: $_____________ (verify current amount)

☐ Fee Petition Process (42 U.S.C. § 406(a)(1))
- Requires itemized services and time records
- No automatic percentage limit
- Subject to SSA review for reasonableness

SCOPE OF REPRESENTATION

Levels of Appeal Covered:

☐ Initial Application
☐ Reconsideration
☐ Administrative Law Judge (ALJ) Hearing
☐ Appeals Council Review
☐ Federal Court Review

Types of Claims:

☐ Title II - Social Security Disability Insurance (SSDI)
☐ Title XVI - Supplemental Security Income (SSI)
☐ Title II - Disabled Widow(er)'s Benefits
☐ Title II - Disabled Adult Child Benefits
☐ Childhood Disability Benefits

Services to Be Provided:

☐ Review and analysis of medical records
☐ Gathering additional medical evidence
☐ Obtaining treating physician statements
☐ Preparation of legal briefs and memoranda
☐ Representation at hearings
☐ Communication with SSA on claimant's behalf
☐ Post-hearing submissions
☐ Appeals Council briefing
☐ Other: _________________________________________________

FEE TERMS AND CONDITIONS

Standard Fee Agreement Terms:

1. Contingency Basis:
This agreement is contingent upon a favorable decision resulting in past-due benefits. If no past-due benefits are awarded, no fee is owed.

2. Fee Calculation:
The fee shall be the lesser of:
- Twenty-five percent (25%) of total past-due benefits, OR
- The maximum fee permitted under 42 U.S.C. § 406(a)(2)(A)

3. Direct Payment Authorization:
Claimant authorizes SSA to withhold and pay the representative fee directly from past-due benefits pursuant to 42 U.S.C. § 406(a)(4).

Expenses and Costs:

☐ Option A: Claimant responsible for all costs and expenses regardless of outcome
☐ Option B: Representative advances costs; reimbursed from award
☐ Option C: Representative absorbs costs if claim unsuccessful
☐ Option D: Other arrangement: _________________________________________________

Estimated Costs May Include:
- Medical record copying fees: $__________
- Medical expert fees: $__________
- Vocational expert fees: $__________
- Travel expenses: $__________
- Other: $__________

REPRESENTATIVE OBLIGATIONS

The representative agrees to:

☐ Act with reasonable diligence and promptness
☐ Keep claimant informed of case status
☐ Comply with all SSA rules and regulations
☐ Maintain confidentiality of claimant information
☐ Provide copies of all documents filed on claimant's behalf
☐ Explain the claims process and hearing procedures
☐ Prepare claimant for hearings and examinations
☐ Timely respond to SSA communications
☐ Withdraw only with proper notice and SSA approval

CLAIMANT OBLIGATIONS

The claimant agrees to:

☐ Provide truthful and complete information
☐ Promptly inform representative of any changes in:
☐ Address or contact information
☐ Medical condition or treatment
☐ Work activity
☐ Income or resources (SSI cases)
☐ Living arrangements (SSI cases)
☐ Attend all scheduled appointments and hearings
☐ Cooperate with medical examinations
☐ Sign necessary authorizations for medical records
☐ Notify representative of any SSA communications
☐ Pay agreed-upon expenses as specified above

TERMINATION OF REPRESENTATION

By Claimant:

Claimant may terminate this agreement at any time by written notice. Representative may be entitled to reasonable compensation for services rendered prior to termination.

By Representative:

Representative may withdraw from representation for good cause, including:
☐ Claimant's failure to cooperate
☐ Claimant's material misrepresentation
☐ Conflict of interest
☐ Other ethical obligations requiring withdrawal

Withdrawal Procedure:
Representative shall provide written notice to claimant and file appropriate notice with SSA (Form SSA-1696 with withdrawal indication).

FEE DISPUTES

If claimant disagrees with the fee charged, claimant may:

1. Request administrative review by SSA
2. Object to fee approval within 15 days of notice
3. File written objection with the decision-maker who approved the fee

SSA Contact for Fee Disputes:
Social Security Administration
Office of Hearings Operations
[Insert Regional Address]

SSA FEE AGREEMENT REQUIREMENTS

For SSA approval, this fee agreement must:

☐ Be in writing
☐ Be signed by both claimant and representative
☐ Specify the fee arrangement
☐ Not charge an excessive fee
☐ Be filed with SSA before a favorable decision

Filing Deadline: Fee agreement must be filed with SSA before the date of favorable decision to be eligible for fee agreement process.

ADDITIONAL TERMS

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ACKNOWLEDGMENTS

Claimant Acknowledgments:

☐ I have read and understand this agreement
☐ I have received a copy of this agreement
☐ I understand the fee is contingent on receiving past-due benefits
☐ I understand I may request SSA review of any fee charged
☐ I authorize direct payment of approved fees from my benefits
☐ I understand I may have to pay costs/expenses as outlined above
☐ I have had opportunity to ask questions about this agreement

Representative Acknowledgments:

☐ I agree to abide by SSA rules of conduct for representatives
☐ I will file this agreement with SSA as required
☐ I will provide claimant with copies of all filings
☐ I understand fees are subject to SSA approval

SIGNATURES

CLAIMANT:

Signature: _________________________________ Date: _________________

Printed Name: _________________________________________________

REPRESENTATIVE:

Signature: _________________________________ Date: _________________

Printed Name: _________________________________________________

Bar Number: _________________________________________________

REQUIRED ATTACHMENTS

☐ Form SSA-1696 (Appointment of Representative)
☐ Form SSA-1695 (Identifying Information for Possible Direct Payment)
☐ Copy of representative's photo ID
☐ Copy of claimant's photo ID
☐ Proof of representative's good standing with licensing authority

FOR SSA USE ONLY

Date Received: _________________
Approved: ☐ Yes ☐ No
Approved Fee Amount: $_________________
Reviewing Official: _________________________________________________
Date of Decision: _________________

This fee agreement is made pursuant to 42 U.S.C. § 406 and 20 C.F.R. §§ 404.1720-1730 and 416.1520-1530. The terms are subject to SSA approval and applicable regulations.