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Complete the Fee Agreement for Representation Before the Social Security Administration (Form SSA-1693)
Instructions for Representatives
This service allows you to electronically complete the Fee Agreement for Representation Before the Social Security Administration (Form
SSA-1693). You, the claimant, and up to five additional representatives may sign the form and submit it to us electronically. Do not use this
electronic form if there are more than six representatives who will be seeking a fee for services provided on this claim. Before you
begin, you will need the following information:
• Your valid email address.
• The claimant's valid email address.
• The valid email addresses for up to five additional representatiYes who will be signing this fee agreement.
IMPORTANT: We will not receive or process the form until you, the claimant, and any additional representatiYe(s) whose email address(es)
you provide have completed the steps below and electronically signed the form.
Step One. You, the Appointed Representative, must complete your designated sections of the form, sign the form electronically, and select
"Click to Sign" to submit the form.
Before beginning the form, you w�ll first enter and confirm the email addresses for you, the claimant, and up to five additional
representati,·e.(s) into the application online. We will refer to these individuals as "all parties" in these. instmctions.
You ,viii also create a password that will be required for all parties to access the form. You should pro,·ide the password to the other parties by
phone, in person, or SMS text message. (standard message and data rates may apply). If you are unable to contact the. other parties by phone,
in person, or by text, then you may send the password in a separate email message. You will not be able to reset the password. If it is lost or
forgotten, you will ha,·e to restart the process.
You ,viii receive an email from adobesign@adobesign.com containing a link and instructions on how to access the form.
NOTE: After you submit the form, all other parties will receive an email from adobesign@adobesign.com containing a link and instructions
for accessing and signing the form. The form must be completed by all parties within ten (I0) calendar days after you initiate the process
online (i.e., when you enter all of the parties' email addresses in order to receive an email with a link to the form). You should inform all
parties about the. importance of taking action upon receipt of the email. If all parties do not complete, sign, and submit the form within ten
(10) calendar days, you will need to restart the process.
Step Two. After you have completed Step One, the remaining parties will recei,·e. an email with a link to access and re,·iew the partially
completed form, complete their designated sections, sign the form electronically, and select "Click to Sign" to submit the form. There is no
specific order required for the other parties to complete the form, but all must electronically sign and submit it within the 10-day period.
© Social Security
Fee Agreement for Representation
We recommend that you verify the accuracy of the email addresses of all parties and make note of the password prior to
submission.
You will have to restart the process if any of the following situations apply:
•
The password is lost or forgotten. The password cannot be reset.
•
You do not receive an email notification within a few minutes of your online submission. Be sure to check your junk
folder.
• All parties do not electronically sign and submit the form within ten (10) calendar days.
Appointed Representative's Email
Enter Appointed Representative's Email
Confirm Appointed Representative's Email
Confirm Appointed Representative's Email
I
I
I
I
Claimant's Email
Enter Claimant's Email
Confirm Claimant's Email
Confirm Claimant's Email
Representative #2's Email
Enter Representative #2's Email
Confirm Representative #2's Email
Confirm Representative #2's Email
Add Signer
Remove Signer
Document Name
Fee Agreement for Representation Before the Social Security Administration
Password Required
Password must contain at least 8 characters, 1 uppercase, 1 lowercase, and 1 number.
Password
Confirm Password
D
Show Password
Completion Deadline
06/20/2021
submit
G
I
Wed 6/9/2021 9:45 AM
Social Security Administration
[EXTERNAL) Social Security Administration Has Sent You Fee Agreement for Representation Before the Social Security Administration
To
Appointed Rep Email Address
Retention Policy
Delete_7_Year_Default (7 years)
8 If there are problems with how this message is displayed, click here to view it in a web browser.
Expires
Gn/2028
. � Social Security
'.
Social Security Administration requests your signature
Fee Agreement for Representation Before the Social Security Administration
Form Expires On June 14, 2021
Review and sign
THIS LINK EXPIRES IN TEN (10) CALENDAR DAYS.
You have a document to review and sign. You can access the document using the link above. For additional security, the appointed
representative has set a password for this document. If you are not the appointed representative, you will need to contact the appointed
representative to get the password in order to review this document. If any of the information in the document is incorrect or if you
disagree with any of the information, the appointed representative should restart the process.
This link is personalized for you and, for security purposes, we recommend that you do NOT forward/share this email or link with others.
If you DO forward/share this email or link with others, you accept the risk that, by sharing your personal information, the person assisting
you may misuse your personal information. If you have any questions about this email or feel that you received this in error, please
contact SSA at 1-800-772-1213 (TTY 1-800-325-0778) between 8:00 am - 7:00 pm, Monday through Friday.
Suspect Social Security fraud?
If you suspect Social Security fraud, please visit https://oig.ssa.gov/report or call the Inspector General's Fraud Hotline at 1-800-2690271 (TTY 1-800-501-2101).
SOCIAL SECURITY ADMINISTRATION
■�
Sign
By proceeding. you agree that this agreement may be signed using electronic or handwritten signatures.
To ensure that you continue receiving our emails. please add adobe5ign@adobesign.ro• to your address book or safe list.
© 2020 Adobe. All rights reserved.
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Page 2 of 2
Form SSA-1693 (3/XX/2021)
Standard Fee Agreement
If the Social Security Administration (SSA) favorably decides my claim(s) and the decision resuffs in past-due benefits, section
206(a)(2) of the Social Security Act permits me to agree to pay my representative(s) a fee that does not exceed the lesser of
25 percent of my past-due benefits or the maximum doflar amount set by the Commissioner of Social Security on the date
SSA authorizes my representative's fee. The maximum amount is $6,000 as of the publication of this form.
Choose One:
*o
*o
I agree to pay the maximum fee as stated in the preceding paragraph.
I agree to pay less than the maximum: S
%.
or
I understand that I, my eligible spouse, any affected auxiliary beneficiary, my representative or the decision maker
have the right to protest the fee authorized under this fee agreement, in writing, within 15 days from the authorization.
I understand that my representative may still request a fee even if my case does not result in past-due benefits, or the decision
is not favorable. If the fee agreement cannot be approved because there are no past-due benefits or for other reasons, my
representative may file a fee petition to request that SSA authorize a fee. I also understand that if there are no past-due
benefits withheld, if not enough past-due benefits are withheld, or if my representative is not eligible for direct payment by SSA,
I will be responsible to pay the authorized fee to my representative directly. SSA is not responsible for authorizing out-ofpocket
costs and expenses for which I may be responsible to pay directly to my representative.
Two-Tiered Fee Agreement (Optional)
Only complete this section if you and your representative(s) have chosen to limit the effect of this fee agreement to a
certain administrative level.
Check only if applicable:
This fee agreement is in effect through this administrative level: Initial
O
Reconsideration
O
Hearing
Q
NIA
QI
understand that a two-tiered fee agreement is not required, but if chosen and SSA favorably decides my claim(s) above the
administrative level indicated above, SSA will disapprove it and my representative(s) may ask SSA to authorize a fee by filing a
fee petition.
Escrow!Trust Accounts or Third-Party Payments (Optional)
Only complete this section if your representative(s) will use an escrow or trust account, or someone other than you or your
spouse, dependents or auxiliary beneficiaries or another individual has paid or will pay your representative a fee.
Check only if applicable:
0 With my consent, my representative(s) has/have or will establish an escrow/trust account in the amount of$ ______
0 My representative will receive a fee from another party (e.g., state, county, private entity) of$ --------and I will have no financial responsibility to pay any fee, unless SSA authorizes the total fee (i.e., the total amount paid by the
third party, me, and/or my spouse, dependents or auxiliary beneficiaries).
Claimant and Representative Signatures
Only representatives who have been properly appointed can be authorized to receive a fee. The claimant and any appointed
representative(s) not waiving a fee are each required to sign this fee agreement. Other representatives can also sign on the form.
Saved
Language I English: US
Claimant's Signature
Date
*Click here to sign
Jun 10, 2021
Representative's Signature
Date
1' W
4
--
/5
8
(±)
.!,
X
© 2021 Adobe. All rights reserved.
Terms Consumer Disclosure Trust Cookle preferences
fJ
Adobe Sign
Options v
Fee Agreement for Representation Before the Social Security Ad...
Required fields completed
Page 2 of 2
Form SSA-1693 (3/XX/2021)
Standard Fee Agreement
If the Social Security Administration (SSA) favorably decides my claim(s) and the decision resuffs in past-due benefits, section
206(a)(2) of the Social Security Act permits me to agree to pay my representative(s) a fee that does not exceed the lesser of
25 percent of my past-due benefits or the maximum doflar amount set by the Commissioner of Social Security on the date
SSA authorizes my representative's fee. The maximum amount is $6,000 as of the publication of this form.
Choose One:
0
I agree to pay the maximum fee as stated in the preceding paragraph.
@ I agree to pay less than the maximum: S 100
or
%.
I understand that I, my eligible spouse, any affected auxiliary beneficiary, my representative or the decision maker
have the right to protest the fee authorized under this fee agreement, in writing, within 15 days from the authorization.
I understand that my representative may still request a fee even if my case does not result in past-due benefits, or the decision
is not favorable. If the fee agreement cannot be approved because there are no past-due benefits or for other reasons, my
representative may file a fee petition to request that SSA authorize a fee. I also understand that if there are no past-due
benefits withheld, if not enough past-due benefits are withheld, or if my representative is not eligible for direct payment by
SSA, I will be responsible to pay the authorized fee to my representative directly. SSA is not responsible for authorizing out-of
pocket costs and expenses for which I may be responsible to pay directly to my representative.
Two-Tiered Fee Agreement (Optional)
Only complete this section if you and your representative(s) have chosen to limit the effect of this fee agreement to a certain
administrative level.
Check only if applicable:
Q
O
Q
This fee agreement is in effect through this administrative level: I nitial @ Reconsideration
Hearing
NIA
I understand that a two-tiered fee agreement is not required, but if chosen and SSA favorably decides my claim(s) above the
administrative level indicated above, SSA will disapprove it and my representative(s) may ask SSA to authorize a fee by filing a
fee petition.
Escrow!Trust Accounts or Third- Party Payments (Optional)
Only complete this section if your representative(s) will use an escrow or trust account, or someone other than you or
your spouse, dependents or auxiliary beneficiaries or another individual has paid or will pay your representative a fee.
o o_____
r.i With my consent, my representative(s) has/have or will establish an escrow/trust account in the amount of$ _1_ _
Check only if applicable:
0
My representative will receive a fee from another party (e.g., state, county, private entity) of$ --------and I will have no financial responsibility to pay any fee, unless SSA authorizes the total fee (i.e., the total amount paid by the
third party, me, and/or my spouse, dependents or auxiliary beneficiaries).
Claimant and Representative Signatures
Only representatives who have been properly appointed can be authorized to receive a fee. The claimant and any appointed
representative(s) not waiving a fee are each required to sign this fee agreement. Other representatives can also sign on the form.
Claimant's Signature
Date
Test 'RetJ
Jun 10, 2021
�Rl'O OunKl.,2621)
Representative's Signature
Date
Ill
By signing,/ agree to both this agreement and the l1.,,,,, •n,01 ,l 'C,1'>,Jt'. My use ofAdobe
Sign isgovemed by the -'1,1,,t,e Tc.01--0,
,,, ,/"'·
ct·ICktO s·1gn
9
Wed 6/9/2021 9:45 AM
Social Security Administration
[EXTERNAL) Social Security Administration Has Sent You Fee Agreement for Representation Before the Social Security Administration
To
Claimant Email
Retention Policy
Address
Delete_7_Year_Default (7 years)
8 If there are problems with how this message is displayed, click here to view it in a web browser.
Expires
Gn/2028
. � Social Security
'.
Social Security Administration requests your signature
Fee Agreement for Representation Before the Social Security Administration
Form Expires On June 14, 2021
Review and sign
THIS LINK EXPIRES IN TEN (10) CALENDAR DAYS.
You have a document to review and sign. You can access the document using the link above. For additional security, the appointed
representative has set a password for this document. If you are not the appointed representative, you will need to contact the appointed
representative to get the password in order to review this document. If any of the information in the document is incorrect or if you
disagree with any of the information, the appointed representative should restart the process.
This link is personalized for you and, for security purposes, we recommend that you do NOT forward/share this email or link with others.
If you DO forward/share this email or link with others, you accept the risk that, by sharing your personal information, the person assisting
you may misuse your personal information. If you have any questions about this email or feel that you received this in error, please
contact SSA at 1-800-772-1213 (TTY 1-800-325-0778) between 8:00 am - 7:00 pm, Monday through Friday.
Suspect Social Security fraud?
If you suspect Social Security fraud, please visit https://oig.ssa.gov/report or call the Inspector General's Fraud Hotline at 1-800-2690271 (TTY 1-800-501-2101).
SOCIAL SECURITY ADMINISTRATION
■�
Sign
By proceeding. you agree that this agreement may be signed using electronic or handwritten signatures.
To ensure that you continue receiving our emails. please add adobe5ign@adobesign.ro• to your address book or safe list.
© 2020 Adobe. All rights reserved.
II Adobe Sign
Sign In
This Document is Password Protected
'
You need a password to access this document.
Enter Password
fJ
Adobe Sign
Fee Agreement for Representati. ..
Options v
z
11)
Next Required
■
Page 2 of 2
FOffil SSA-1693 (3/XX/2021)
Standard Fee Agreement
If the Social Security Administration (SSA) favorably decides my c/aim(s) and the decision results in past-due benefits, section
206(a)(2) of the Social Security Act permits me to agree to pay my representative(s) a fee that does not exceed the lesser of
25 percent of my past-due benefrts or the maximum dollar amount set by the Commissioner of Social Security on the date
SSA authorizes my representative's fee. The maximum amount is $6,000 as of the publication of this form.
Choose One:
ID
I agree to pay the maximum fee as stated in the preceding paragraph.
� I agree to pay less than the maximum: S
100
-------
or
%.
I understand that I, my eligible spouse, any affected auxiliary beneficiary, my representative or the decision maker
have the right to protest the fee authorized under this fee agreement, in writing, within 15 days from the authorization.
I understand that my representative may still request a fee even if my case does not result in past-due benefits, or the decision
is not favorable. If the fee agreement cannot be approved because there are no past-due benefits or for other reasons, my
representative may file a fee petition to request that SSA authorize a fee. I also understand that if there are no past-due
benefits withheld, if not enough past-due benefits are withheld, or if my representative is not eligible for direct payment by
SSA, I will be responstble to pay the authorized fee to my representative directly. SSA is not responsible for authorizing out-of
pocket costs and expenses for which I may be responsible to pay directly to my representative.
Two-Tiered Fee Agreement (Optional)
Only complete this section if you and your representative(s) have chosen to limit the effect of this fee agreement to a certain
administrative level.
Check only if applicable:
This fee agreement is in effect through this administrative level: Initial@ Reconsideration O
Hearing
O
NIAO
I understand that a two-tiered fee agreement is not required, but if chosen and SSA favorably decides my claim(s) above the
administrative level indicated above, SSA will disapprove it and my representative(s) may ask SSA to authorize a fee by filing a
fee petition.
Escrow/Trust Accounts or Third-Party Payments (Optional)
Only complete this section if your representative(s) will use an escrow or trust account, or someone other than you or your
spouse, dependents or auxiliary beneficiaries or another individual has or will pay your representative a fee.
Check only if applicable:
Ill
D
With my consent my representative(s) has/have or will establish an escrow/trust account in the amount of$ _1 0
_ _0____
_
My representative will receive a fee from another party (e.g., state, county, private entity) of$ ________
and I will have no financial responsibility to pay any fee, unless SSA authorizes the total fee (i.e., the total amount paid by the
third party, me, and/or my spouse, dependents or auxiliary beneficiaries).
Claimant and Representative Signatures
Only representatives who have been properly appointed can be authorized to receive a fee. The claimant and any appointed
representative(s) not waiving a fee are each required to sign this fee agreement. other representatives can also sign on the form.
Jun 10, 2021
Click here to sign
Saved
Language I English: US
Claimant's Signature
Date
Tfll R11>1Ji-o.zaz1 IS.J7EDT)
Jun 10, 2021
Representative's Signature
Date
1' '¥
4
--
/5
8
(±)
.!,
X
© 2021 Adobe. All rights reserved.
Terms Consumer Disclosure Trust Cookle preferences
fJ
Adobe Sign
Fee Agreement for Representati...
Options v
Required fields completed
Form SSA-1693 (3/XX/2021)
Page 2 of 2
Standard Fee Agreement
If the Social Security Administration (SSA) favorably decides my claim(s) and the decision results in past-due benefits, section
206(a)(2) of the Social Security Act permits me to agree to pay my representative(s) a fee that does not exceed the lesser of
25 percent of my past-due benefrts or the maximum dollar amount set by the Commissioner of Social Security on the date
SSA authorizes my representative's fee. The maximum amount is $6,000 as of the publication of this form.
Choose One:
[] I agree to pay the maximum fee as stated in the preceding paragraph.
� I agree to pay less than the maximum S
100
-------
or
%.
I understand that I, my eligible spouse, any affected auxiliary beneficiary, my representative or the decision maker
have the right to protest the fee authorized under this fee agreement, in writing, within 15 days from the authorization.
I understand that my representative may still request a fee even if my case does not result in past-due benefits, or the decision
is not favorable. If the fee agreement cannot be approved because there are no past-due benefits or for other reasons, my
representative may file a fee petition to request that SSA authorize a fee. I also understand that if there are no past-due
benefits withheld, if not enough past-due benefits are withheld, or if my representative is not eligible for direct payment by
SSA, I will be responstble to pay the authorized fee to my representative directly. SSA is not responsible for authorizing out-of
pocket costs and expenses for which I may be responstble to pay directly to my representative.
Two-Tiered Fee Agreement (Optional)
Only complete this section if you and your representative(s) have chosen to limit the effect of this fee agreement to a certain
administrative level.
Check only if applicable:
This fee agreement is in effect through this administrative level: Initial@ Reconsideration O
O
Hearing
NIAO
I understand that a two-tiered fee agreement is not required, but if chosen and SSA favorably decides my claim(s) above the
administrative level indicated above, SSA will disapprove it and my representative(s) may ask SSA to authorize a fee by filing
a fee petition.
Escrow/Trust Accounts or Third-P arty Payments (Optional)
Only complete this section if your representative(s) will use an escrow or trust account, or someone other than you or your
spouse, dependents or auxiliary beneficiaries or another individual has paid or will pay your representative a fee.
Check only if applicable:
121 With my consent my representative(s) has/have or will establish an escrow/trust account in the amount of$ _10_ _0____ _
D
My representative will receive a fee from another party (e.g., state, county, private entity) of$ ________
and I will have no financial responsibility to pay any fee, unless SSA authorizes the total fee (i.e., the total amount paid by the
third party, me, and/or my spouse, dependents or auxiliary beneficiaries).
Claimant and Representative Signatures
Onfy representatives who have been properly appointed can be authorized to receive a fee. The claimant and any appointed
representative(s) not waiving a fee are each required to sign this fee agreement. other representatives can also sign on the form.
�Cbm
[EXTERNAL) Social Security Administration Has Sent You Fee Agreement for Representation Before the Social Security Administration
To
Additional Rep Email Address
Retention Policy
Delete_7_Year_Default (7 years)
8 If there are problems with how this message is displayed, click here to view it in a web browser.
Expires
Gn/2028
. � Social Security
'.
Social Security Administration requests your signature
Fee Agreement for Representation Before the Social Security Administration
Form Expires On June 14, 2021
Review and sign
THIS LINK EXPIRES IN TEN (10) CALENDAR DAYS.
You have a document to review and sign. You can access the document using the link above. For additional security, the appointed
representative has set a password for this document. If you are not the appointed representative, you will need to contact the appointed
representative to get the password in order to review this document. If any of the information in the document is incorrect or if you
disagree with any of the information, the appointed representative should restart the process.
This link is personalized for you and, for security purposes, we recommend that you do NOT forward/share this email or link with others.
If you DO forward/share this email or link with others, you accept the risk that, by sharing your personal information, the person assisting
you may misuse your personal information. If you have any questions about this email or feel that you received this in error, please
contact SSA at 1-800-772-1213 (TTY 1-800-325-0778) between 8:00 am - 7:00 pm, Monday through Friday.
Suspect Social Security fraud?
If you suspect Social Security fraud, please visit https://oig.ssa.gov/report or call the Inspector General's Fraud Hotline at 1-800-2690271 (TTY 1-800-501-2101).
SOCIAL SECURITY ADMINISTRATION
■�
Sign
By proceeding. you agree that this agreement may be signed using electronic or handwritten signatures.
To ensure that you continue receiving our emails. please add adobe5ign@adobesign.ro• to your address book or safe list.
© 2020 Adobe. All rights reserved.
II Adobe Sign
Sign In
This Document is Password Protected
'
You need a password to access this document.
Enter Password
fJ
Adobe Sign
Next Required
Fee Agreement for Representati. ..
Options v
IJ
Page 2 of 2
FOffil SSA-1693 (3/XX/2021)
Standard Fee Agreement
If the Social Security Administration (SSA) favorably decides my c/aim(s) and the decision results in past-due benefits, section
206(a)(2) of the Social Security Act permits me to agree to pay my representative(s) a fee that does not exceed the lesser of
25 percent of my past-due benefrts or the maximum dollar amount set by the Commissioner of Social Security on the date
SSA authorizes my representative's fee. The maximum amount is $6,000 as of the publication of this form.
Choose One:
ID
I agree to pay the maximum fee as stated in the preceding paragraph.
� I agree to pay less than the maximum: S
100
-------
or
%.
I understand that I, my eligible spouse, any affected auxiliary beneficiary, my representative or the decision maker
have the right to protest the fee authorized under this fee agreement, in writing, within 15 days from the authorization.
I understand that my representative may still request a fee even if my case does not result in past-due benefits, or the decision
is not favorable. If the fee agreement cannot be approved because there are no past-due benefits or for other reasons, my
representative may file a fee petition to request that SSA authorize a fee. I also understand that if there are no past-due
benefits withheld, if not enough past-due benefits are withheld, or if my representative is not eligible for direct payment by
SSA, I will be responstble to pay the authorized fee to my representative directly. SSA is not responsible for authorizing out-of
pocket costs and expenses for which I may be responsible to pay directly to my representative.
Two-Tiered Fee Agreement (Optional)
Only complete this section if you and your representative(s) have chosen to limit the effect of this fee agreement to a certain
administrative level.
Check only if applicable:
This fee agreement is in effect through this administrative level: Initial@ Reconsideration O
Hearing
O
NIAO
I understand that a two-tiered fee agreement is not required, but if chosen and SSA favorably decides my claim(s) above the
administrative level indicated above, SSA will disapprove it and my representative(s) may ask SSA to authorize a fee by filing a
fee petition.
Escrow/Trust Accounts or Third-P arty Payments (Optional)
Only complete this section if your representative(s) will use an escrow or trust account, or someone other than you or your
spouse, dependents or auxiliary beneficiaries or another individual has paid or will pay your representative a fee.
Check only if applicable:
Ill
D
0
With my consent my representative(s) has/have or will establish an escrow/trust account in the amount of$ _1 _ _0
____ _
My representative will receive a fee from another party (e.g., state, county, private entity) of$ ________
and I will have no financial responsibility to pay any fee, unless SSA authorizes the total fee (i.e., the total amount paid by the
third party, me, and/or my spouse, dependents or auxiliary beneficiaries).
Claimant and Representative Signatures
Only representatives who have been properly appointed can be authorized to receive a fee. The claimant and any appointed
representative(s) not waiving a fee are each required to sign this fee agreement. other representatives can also sign on the form.
Jun 10, 2021
-
V,
a,
Claimant's Signature
Date
Tfll R11>1Ji-o.zaz1 IS.J7EDT)
Jun 10, 2021
Representative's Signature
Date
1' --.v
Language I English: US
4
--
1s
8
(±)
.!,
X
© 2021 Adobe. All rights reserved.
Terms Consumer Disclosure Trust Cookle preferences
11 na2.documents.adobe.com/public/agreements/view/CBJCHBCA A B A A F_RVTf1qxjC1 ur50VjQb512-4OWi A3Oh?type=esign&tsid=CBFCI...
II
Adobe Sign
Page 2 of 2
Form SSA-1693 (3/XX/2021)
••
•
Fee Agreement for Representation Before
the Social Security Administration,
Created Jun 10, 2021 3:12 PM
Standard Fee Agreement
If the Social Security Administration (SSA) favorably decides my claim(s) and the decision results in past-due benefits, section
206(a)(2) of the Social Security Act permits me to agree to pay my representative(s) a fee that does not exceed the lesser of
25 percent of my past-due benefits or the maximum dollar amount set by the Commissioner of Social Security on the date
SSA authorizes my representative's fee. The maximum amount is $6,000 as of the publication of this form.
From: Social S�curity Administration
( no-reply@)ssa.gov)
Choose One:
l2lJ
8 Guest
Sign In
...
D
�
Status: Signed
I agree to pay the maximum fee as stated in the preceding paragraph.
I agree to pay less than the maximum:$ 100
or
Message: THIS LINK EXPIRES IN TEN (10)
%.
C ALENDAR DAYS. You have a document to
review and sign. You can access the
I understand that I, my eligible spouse, any affected auxiliary beneficiary, my representative or the decision maker
have the right to protest the fee authorized under this fee agreement, in writing, within 15 days from the authorization.
document using the link above. For additional
security, the originating representative has set
I understand that my representative may still request a fee even if my case does not result in past-due benefits, or the decision
is not favorable. If the fee agreement cannot be approved because there are no past-due benefits or for other reasons, my
representative may file a fee petition to request that SSA authorize a fee. I also understand that if there are no past-due
benefits withheld, if not enough past-due benefits are withheld, or if my representative is not eligible for direct payment by
SSA, I will be responsible to pay the authorized fee to my representative directly. SSA is not responsible for authorizing out-of
pocket costs and expenses for which I may be responsible to pay directly to my representative.
See more
Actions
Two-Tiered Fee Agreement (Optional)
Only complete this section if you and your representative(s) have chosen to limit the effect of this fee agreement to a certain
administrative level.
Check only if applicable:
This fee agreement is in effect through this administrative level: Initial@ ReconsiderationO
Hearing
O
NIAO
I understand that a two-tiered fee agreement is not required, but if chosen and SSA favorably decides my claim(s) above the
administrative level indicated above, SSA will disapprove it and my representative(s) may ask SSA to authorize a fee by filing a
fee petition.
Escrow/Trust Accounts or Third-party Payments (Optional)
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Only complete this section if your representative(s) will use an escrow or trust account, or someone other than you or your
spouse, dependents or auxiliary beneficiaries or another individual has paid or will pay your representative a fee.
Check only if applicable:
IZI With my consent my representative(s) has/have or will establish an escrow/trust account in the amount of$ _1_0_0_____
D My representative will receive a fee from another party (e.g., state, county, private entity) of$ _________
and I will have no financial responsibility to pay any fee, unless SSA authorizes the total fee (i.e., the total amount paid by the
third party, me, and/or my spouse, dependents or auxiliary beneficiaries).
Claimant and Representative Signatures
Only representative who have been properly appointed can be authorized to receive a fee. The claimant and any appointed
representative(s) not waiving a fee are each required to sign this fee agreement. Other representatives can also sign on the form.
rwc/e4twtt:
Jun 10, 2021
Claimant's Signature
Date
Test Claimant (Jun 10, 202115 :24 EDT)
Jun 10, 2021
Representative's Signature
Date
...
Language I English: US
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| File Type | application/pdf |
| File Modified | 2021-06-23 |
| File Created | 2021-05-17 |