Last Update: 2/25/05 (Transmittal I-1-48)
Use Form SSA-1560A-U5 (Authorization to Charge and Collect a Fee) (see POMS GN 03930.160A.) to notify the representative and the claimant of the fee the Social Security Administration (SSA) authorized. Attach to the SSA-1560-U5 a brief, but complete, explanation tailored to the circumstances. (See B. below.)
Prepare a duplicate SSA-1560A-U5 when there is more than one family unit.
To prepare Form SSA-1560A-U5:
Enter the identifying information (i.e., claimant's name, wage earner's name (if different from the claimant's name), wage earner's Social Security number, type of claim, and related Social Security number, if any). If one or more auxiliary beneficiaries are involved, add “and Family” after the claimant's name.
Enter the representative's name and address. If he/she is an attorney, use one of the following with the address:
(Mr. or Ms.) (Name)Enter the fee amount authorized after “You are authorized to charge and collect a fee in the amount of $_____ ......” Make sure it agrees with the amount finally authorized. Designate whether one or more auxiliary beneficiaries are involved.
Enter the address to which a party must send any request for administrative review as follows:
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If Authorizer Is: |
Fill in with: |
|---|---|
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Administrative Law Judge (ALJ) |
Regional Chief ALJ's name (RCALJ who has jurisdiction over the claimant's servicing hearing office (HO)) and Regional Office address |
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Attorney Fee Branch (AFB) |
Deputy Chair of the Appeals Council (AC) and the AC address |
Designate the appropriate paragraph about the means of fee payment, if available, as well as the reference to the attached notice.
Enter the authorizing official information and the name and address of the claimant or auxiliary beneficiary(ies).
EXCEPTION:
Do not enter authorizing official information if you are recommending a fee greater than $7,000.
The fee authorizer should follow the sequence below when explaining his/her conclusions and the weight or significance he/she attached to the various factors.
State the amount of the fee.
Positive aspects Summarize those services that advanced the development of the claim, or contributed significantly to a favorable determination. If the authorized fee is greater than that requested, explain why it is reasonable.
Neutral or negative aspects
Summarize those services:
that were not provided in proceedings before SSA;
that negatively affected the development of the claim;
the value of which is compromised because the time spent is unreasonable; and/or
that although neutral, do not support a fee in the amount requested.
The fee authorizer may include the following sample paragraphs as appropriate:
Retainer fee paid by claimant
Retainer fee is less than the authorized fee and there are withheld benefits:
Because the claimant previously paid you a retainer fee of $____ for your services and you are holding those funds in an escrow account, we will send you the remaining balance out of the funds withheld from the claimant's past-due benefits.
Retainer fee is less than the authorized fee and there are no withheld benefits:
The claimant previously paid $___ towards your fee and you are holding those funds in an escrow account. Therefore, the balance remaining for your services is $____. You should look to the claimant for payment of the balance.
Money in escrow account exceeds the authorized fee:
The claimant previously paid $____ towards your fee and you are holding those funds in an escrow account. Because this amount exceeds the amount of the fee you are authorized to collect, you must refund $____ to the claimant.
Concurrent Title II and Title XVI Cases:
The fee approved is for all services performed in connection with both claims.
State paid fee of known amount:
The amount you are authorized to charge for your services includes the fee of $ (1) that the State of (2) paid or will pay you to represent the claimant in a claim for benefits under title XVI of the Social Security Act.
Fill-ins:
the amount of the State-paid fee
name of State that paid or will pay the fee.
State paid fee of unknown amount
We do not know the amount of the fee you received or will receive from the State of (1) for representing the claimant in a claim for benefits under title XVI of the Social Security Act. The amount you are authorized to charge for your services includes any fee that the State of (1) paid or will pay you.
Fill-in:
Name of State that paid or will pay a fee.
NOTE:
If the field office (FO) or processing center (PC) receives a fee authorization without an explanation for the fee amount, that office may return the fee authorization to the authorizer.
The fee authorizing staff will distribute the SSA-1560A-U5 and related documents as follows:
mail the representative's copy (original) to the representative;
mail the claimant's copy to the claimant;
in concurrent titles II and XVI claims and in title XVI only claims, mail the FO copy to the appropriate FO, otherwise discard this copy; and
place a copy of Form SSA-1560A-U5, Form SA-1560-U4, the benefit information (if available), and the HA-505 route slip or fax receipt (see below) in the HO or appeals file.
Fax the following to the effectuating component (see I-1-2-114 (A.) for the fax cover sheet and PC fax numbers):
claim file copy of the Form SSA-1560-U4, and
claim file copy of Form SSA-1560A-U5.
NOTE:
HOs and the AFB must use the fax numbers listed on the cover sheet at I-1-2-114 (A.) when transmitting the completed Form SSA-1560A-U4 to the PC. The receiving fax machine produces a digital image of the fee authorization that the PC personnel can access from a personal computer.
Use the route slip, Form HA-505, to mail the following to the effectuating component:
claim file copy of Form SSA-1560-U4, and
claim file copy of Form SSA-1560A-U5.
Use the route slip, Form HA-505, to mail the following to the component that has the claim file:
claim file copy of Form SSA-1560-U4, and
claim file copy of Form SSA-1560A-U5.
When a fee is authorized, enter the approval date and amount authorized into the component's tracking system.