Form SSA-1560-U4 Petition to Obtain Approval of a Fee for Representing a

DRAFT
SOCIAL SECURITY ADMINISTRATION

PETITION TO OBTAIN APPROVAL OF A FEE FOR REPRESENTING A
CLAIMANT BEFORE THE SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0104
IMPORTANT
INFORMATION
ON REVERSE SIDE

PRIVACY ACT NOTICE: Your response to this request is voluntary, but the Social Security Administration may not approve
any fee unless it receives the information this form requests. The Administration will use the information to determine a fair
value for services you rendered to the claimant named below, as provided in sections 206 and 1631(d) of the Social Security Act
(42 U.S.C. 406 and 1383(d)).
I request approval to charge a fee of →
Fee $
(Show the dollar amount)
Mr.
For services performed as the representative of →
Mrs.
My Services Began: _____ / _____ / ______
Ms.
Month Day
Year
Type(s) of claim(s)
My Services Ended: : _____ / _____ / ______
Enter the name and the Social Security number of the person on whose Social Security record the claim is based.
_ _ _/ _ _/ _ _ _ _
1.
Itemize on a separate page or pages the services you rendered before the Social Security Administration (SSA). List each
meeting, conference, item of correspondence, telephone call, and other activity in which you engaged, such as research,
preparation of a brief, attendance at a hearing, travel, etc., related to your services as representative in this case. Attach to this
petition the list showing the dates, the descriptions of each service, the actual time spent in each, and the total hours.
2.
Have you and your client entered into a fee agreement for services before SSA?
 YES  NO
If “yes,” please specify the amount on which you agreed, and attach a copy of the
and  See attached
agreement to this petition.
$
3.
(a) Have you received, or do you expect to receive, any payment toward your fee
 YES  NO
from any source other than from funds which SSA may be withholding for fee payment?
(b) Do you currently hold in a trust or escrow account any amount of money you
 YES  NO
received toward payment of your fee?
If “yes” to either or both of the above, please specify the source(s) and the amount(s).
Source:__________________________________________________________________________ $______________
Source:__________________________________________________________________________ $______________
Note: If you receive payment(s) after submitting this petition, but before the SSA approves a fee, you have an
affirmative duty to notify the SSA office to which you are sending this petition.

4.

Have you received, or do you expect to receive, reimbursement for expenses you incurred?
 YES  NO
If “yes,” please itemize your expenses and the amounts on a separate page.
5.
Did you render any services relating to this matter before any State or Federal court?
 YES  NO
If “yes,” what fee did you or will you charge for services in connection with the court proceedings? $___________
Please attach a copy of the court order if the court has approved a fee.
6.
Have you been disbarred or suspended from a court or bar to which you were previously admitted to practice as an attorney?
 YES  NO
7.
Have you been disqualified from participating in or appearing before a Federal program or agency?
 YES  NO
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements
or forms, and it is true and correct to the best of my knowledge.
Signature of Representative
Date:
Address (include Zip Code)
Firm with which associated, if any

Telephone No. and Area Code

[Note: The following is optional. However, SSA can consider your fee petition more promptly if your client knows and already agrees
with the amount you are requesting.]
I understand that I do not have to sign this petition or request. It is my right to disagree with the amount of the fee requested or any
information given, and to ask more questions about the information given in this request (as explained on the reverse side of this form.
I have marked my choice below.
 I agree with the $_____ fee which my representative is asking to charge and collect. By signing this request, I am not giving up my
right to disagree later with the total fee amount the Social Security Administration authorizes my representative to charge and collect.
OR
 I do not agree with the requested fee or other information given here, or I need more time. I understand I must call, visit, or write to
SSA within 20 days if I have questions or if I disagree with the fee requested or any information shown (as explained on the reverse
sides of this form).
Signature of Claimant
Date
Address (include Zip Code)
Form SSA-1560-U4 (1-2007)(EF 1-2007)
Destroy Prior Editions

Telephone No. and Area Code
4th copy – change to “ODAR COPY”

INSTRUCTIONS FOR USING THIS PETITION
Any attorney or other representative who wants to charge or collect a fee for
services, rendered in connection with a claim before the Social Security
Administration (SSA), is required by law to first obtain SSA’s approval of the
fee [sections 206(a) and 1631(d)(2) of the Social Security Act (42 U.S.C.
406(a) and 1383(d)(2)) and sections 404.1720 and 416.1520 of Social Security
Administration Regulations Numbers 4 and 16, respectively.]
The only exceptions are if the fee is for services rendered (1) when a nonprofit
organization or government agency pays the fee and any expenses out of
funds which a government entity provided or administered and the claimant
incurs no liability, directly or indirectly, for the cost of such services and
expenses; (2) in an official capacity such as that of legal guardian, committee,
or similar court-appointed office and the court has approved the fee in
question; or (3) in representing the claimant before a court of law. A
representative who has rendered services in a claim before both SSA and a
court of law may seek a fee from either or both, but generally neither tribunal
has the authority to set a fee for services rendered before the other [42 U.S.C.
406(a) and (b)].

When to File a Fee Petition
The representative should request fee approval only after completing all
services (for the claimant and any auxiliaries). The representative has the
option to petition either before or after SSA effectuates the determination(s).
In order to receive direct payment of all or any part of an authorized fee from
past-due benefits, the representative who is eligible for direct fee payment, as
defined under “Collection of the Fee,” should file a request for fee approval,
or written notice of intent to file a request within 60 days of the date of the
notice of the favorable determination is mailed. When there are multiple
claims on one account and the representative who is eligible for direct fee
payment will not file the petition within 60 days after the mailing date of the
first notice of favorable determination, he or she should file a written notice of
intent to file a request for fee approval within the 60-day period.

Where to File the Petition
The representative must first give the “Claimant’s Copy” of the SSA-1560-U4
petition to the claimant for whom he or she rendered services, with a copy of
each attachment. The representative may then file the original and third
carbon copy, the “ODAR Copy,” of the SSA-1560-U4, and the attachment(s),
with the appropriate SSA office:
•
If a court or the Appeals Council issued the decision, send the petition to
the Office of Disability Adjudication and Review. Attention: Attorney
Fee Branch, 5107 Leesburg, Pike, Falls Church, VA 22041-3255.
•
If an Administrative Law Judge issued the decision, send the petition to
him or her using his or her office address.
•
In all other cases, send the petition to the reviewing office address which
appears at the top right of the notice of award or notice of disapproved
claim.

SSA notifies both the representative and the claimant of the amount which it
authorizes the representative to charge. If either or both disagree, SSA will
further review the fee authorization when the claimant or representative sends
a letter, explaining the reason(s) for disagreement, to the appropriate office
within 30 days after the date of the notice of authorization to charge and
receive a fee.

Collection of the Fee
Basic liability for payment of a representative’s approved fee rests with the
client. However, SSA will assist in fee collection when SSA awards the
claimant benefits under Title II or Title XVI of the Social Security Act and the
representative is eligible for direct fee payment. To be eligible for direct
payment, the representative must be an attorney or a non-attorney who is
participating in SSA’s direct fee payment demonstration project. In addition;
if the representative was appointed after December 31, 2006, the
representative must register for direct payment before SSA effectuates the
favorable determination. In these cases, SSA generally withholds 25 percent
of the claimant’s past-due benefits. Once the fee is approved, SSA pays the
representative from the claimant’s withheld funds. This does not mean that
SSA will approve as a reasonable fee 25 percent of the past-due benefits.
The amount payable to the representative from the withheld benefits is subject
to the assessment required by section 206(d) and 1631(d)(2)(C) of the Social
Security Act, and it is also subject to offset by any fee payment(s) the
representative has received or expects to receive from an escrow or trust
account. If the approved fee is more than the amount of the withheld benefits,
collection of the difference is a matter between the representative and the
client.
SSA will not withhold past-due benefits to pay the authorized fee to a nonattorney representative who is not participating in the direct payment project.
In addition, SSA will not pay a fee directly to a representative if the
representative was discharged by the client; withdrew from representing the
client; or was appointed to represent the client after December 31, 2006, and
did not register for direct payment before SSA effectuated the determination.
Information on registering for direct fee payment and on becoming eligible to
participate in the non-attorney direct fee payment project is on SSA’s
“Representing Claimants” website: http://www.ssa.gov/representation/.

Penalty for Charging or Collecting an
Unauthorized Fee
Any individual who charges or collects an unauthorized fee for services
provided in any claim, including services before a court which has rendered a
favorable determination, may be subject to prosecution under 42 U.S.C. 406
and 1383 which provide that such individual, upon conviction thereof, shall
for each offense be punished by a fine not exceeding $500, by imprisonment
not exceeding one year, or both.

Computer Matching
Evaluation of a Petition for a Fee
If the claimant has not agreed to and signed the fee petition, SSA does not
begin evaluating the request for 30 days. SSA must decide what is a
reasonable fee for the services rendered to the claimant, keeping in mind the
purpose of the social security or supplemental security income program.
When evaluating a request for fee approval, SSA will consider the (1) extent
and type of services the representative performed; (2) complexity of the case;
(3) level of skill and competence required of the representative in giving the
services; (4) amount of time he or she spent on the case; (5) results achieved;
(6) levels of review to which the representative took the claim and at which he
or she became the representative; and (7) amount of fee requested for services
rendered, including any amount authorized or requested before but excluding
any amount of expenses incurred.
SSA also considers the amount of benefits payable, if any, but authorizes the
fee amount based on consideration of all the factors given here. The amount
of benefits payable in a claim is determined by specific provisions of law
unrelated to the representative’s efforts. Also, the amount of past-due benefits
may depend on the length of time that has elapsed since the claimant’s
effective date of entitlement.

Disagreement

We may also use the information you give us when we match records by
computer. Matching programs compare our records with those of other
Federal, State, or local government agencies. Many agencies may use
matching programs to find or prove that a person qualifies for benefits paid by
the Federal government. The law allows us to do this even if you do not agree
to it.
Explanations about these and other reasons why information you provide us
may be used or given out are available in Social Security Offices. If you want
to learn more about this, contact any Social Security Office.
Paperwork Reduction Act Statement –This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork
Reduction Act of 1995. You do not need to answer these questions unless we
display a valid Office of Management and Budget control number. We
estimate that it will take about 30 minutes to read the instructions, gather the
facts, and answer the questions. You may send comments on our time estimate
above to: SSA, 1338 Annex Building, Baltimore, MD 21235-0001. Send only
comments relating to our time estimate to this address, not the completed
form.

WHAT YOU SHOULD KNOW
This is a copy of a petition, or request, your representative
made to the Social Security Administration (SSA) for
approval to charge a fee for services performed in
connection with your claim.

If You Have Questions or Disagree Now
If you have questions or if you disagree with the fee
requested or any information shown, contact SSA within
20 days from the date of this request. You may call or visit
your local Social Security office or you may write to the
office which last took action in your case.
• Write to the SSA office address which appears at the
top right on your notice of award or notice of
disapproved claim, unless you know that your claim
went to the Appeals Council or an Administrative Law
Judge of the Office of Disability Adjudication and
Review.
• If an Administrative Law Judge made the last decision
in your case, write to him or her using the hearing
office address.
• If the Appeals Council or a court made the last decision
in your case, write to the Office of Disability
Adjudication and Review, Attention: Attorney Fee
Branch, 5107 Leesburg Pike, Falls Church, VA 220413255.
If you decide to call, visit, or write, act quickly so that your
questions reach the correct office within 20 days.

For Your Protection
Until you receive notice that SSA has approved a fee, you
should not pay your representative unless the payment is
held in an escrow or trust account. If you are charged or
pay any money after you receive your copy of this petition
but before you receive notice of the fee amount your
representative may charge, report this to SSA immediately.

What Happens Next
No matter what you may have agreed to in writing, SSA
decides how much your representative may charge you for
his or her services. SSA must decide what is a reasonable
fee for the work your representative did, keeping in mind
the purpose of the social security or supplemental security
income program. SSA does not automatically approve
25 percent of any past-due benefits as a reasonable fee.
SSA must consider the (1) extent and type of services the
representative performed; (2) complexity of your case; (3)
level of skill and competence required of your
representative in giving the services; (4) amount of time he
or she spent on your case; (5) results achieved; (6) levels of
review to which the representative took your claim and at

which he or she became your representative; and (7)
amount of fee he or she requests, including any amount
requested or authorized before but excluding any amount of
expense incurred.
SSA also considers the amount of benefits payable, if any,
but approves a fee amount based on all the factors given
here. This is because the amount of benefits payable to you
is determined by the law and regulations, not by your
representative’s efforts. Also, the amount of past-due
benefits may depend on the length of time that has gone by
since your effective date of entitlement.

What Happens Later
SSA will send you a written notice showing the fee amount
your representative may charge you based on this request.
If you disagree with the amount approved, you must write
to say you disagree and to give your reasons, sending your
letter to the SSA office address shown on the
“Authorization to Charge and Receive a Fee” within 30
days of the date on that notice. You may disagree with
the fee approved, even if you do not disagree now with
the fee amount your representative is requesting.
Our rules say that part of any past-due social security or
supplemental security income benefits payable to you,
under Title II or Title XVI of the Social Security Act must
be used toward the payment of your representative’s fee if
he or she is eligible for direct fee payment. To be eligible
for direct payment, the representative must be an attorney
or a non-attorney who is participating in the direct fee
payment demonstration project.
In addition, if you
appointed your representative after December 31, 2006,
your representative also must register for direct payment
before we effectuate the favorable determination.
The amount SSA may pay your representative directly is
the smallest of the following:
• twenty-five per cent (25%), or one-fourth, of the total
past-due benefits payable to you as a result of the claim;
• the fee amount approved; or
• the amount which you and your representative agreed
upon as the fee for his or her services (shown on the
reverse in item 2 of this petition).
SSA will not pay a fee to a non-attorney representative who
is not participating in the direct payment project. In
addition, SSA will not pay a fee to a representative if you
discharged the representative; the representative withdrew
from representing you; or you appointed the representative
after December 31, 2006, and the representative did not
register for direct payment.