Summary of Revisions to CA-143

SUMMARY OF REVISIONS TO CA-143

ATTORNEY FEE REQUEST

REF OMB 1240-0049

CURRENT EXPIRATION DATE OF 12-31-2012

Page 1

• Included the following accommodation statement on bottom of page

If you have a disability (a substantially limiting physical or mental impairment), please contact our office/claims examiner for information about the kinds of help available, such as communication assistance (alternate formats or sign language interpretation), accommodations and modifications.

Page 2, Instructions Relating to Representative Fee Applications

• 1^st Note, 2d line. “Changed Fees for Representative Services” to “Representative Services”

• 2d paragraph, line 4. Between “fee request… and Further. Added the following sentence: Contingency fees are not allowed in any form. See 20.C.F.R. § 10.702 (a)

• 3d paragraph, last sentence, “after below”. Added, 20 C.F.R. §10.703 (a)

• 3d paragraph, item 4. At end of sentence, Added, 20 C.F.R. §10.702 (b)

Page 3

• 2d paragraph, revised “An incomplete application will be returned for proper completion” to read “An application which is missing the information noted in items 1 through 5 above will be returned to the representative for proper completion.”

• Public Burden Statement, 3^rd sentence, changed estimated change to complete the information from “1” hour to “30” minutes.