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

Form Approved
OMB No. 0960-0104

TOE 850

SOCIAL SECURITY ADMINISTRATION

IMPORTANT
PETITION TO OBTAIN APPROVAL OF A FEE FOR REPRESENTING A
INFORMATION
CLAIMANT BEFORE THE SOCIAL SECURITY ADMINISTRATION
ON REVERSE SIDE
See Revise Privacy Act
PAPERWORK/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 willStatement
use the information to determine a
fair value for services you rendered to the claimant named below, as provided in section 206 of the Social Security Act (42 U.S.C.
406).

Fee $

I request approval to charge a fee of

(Show the dollar amount)

for services performed as the representative of
My Services Began:
Month

My Services Ended:

/
/

Day

/

Year

Type(s) of claim(s)

/

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?
If "yes," please specify the amount on which you agreed, and attach a copy of the
$
agreement to this petition.

3.

(a) Have you received, or do you expect to receive, any payment toward your fee 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 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:

YES
and

NO

See attached
YES

NO

YES

NO

$
$

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?
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?
If "yes," what fee did you or will you charge for services in connection with the court proceedings?

YES

NO

YES

NO

$

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)
Telephone No. and Area Code

Firm with which associated, if any

[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 (2-2005) EF (12-2009)
Destroy Prior Editions

Telephone No. and Area Code

FILE 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 attorney representative or non-attorney
representative whom SSA has found eligible to receive direct payment
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 attorney or non-attorney 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 "OHA 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 Hearings and Appeals. 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 the hearing 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.

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.
Form SSA-1560-U4 (2-2005) EF (12-2009)
Destroy Prior Editions

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
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 change 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 the
representative is an attorney or a non-attorney whom SSA has found
eligible to receive direct payment, and SSA awards the claimant
benefits under Title II or Title XVI of the Social Security Act. In
these cases, SSA generally withholds 25 percent of the claimant's
past-due benefits. Once the fee is approved, SSA pays the attorney or
the eligible non-attorney from the claimant's withheld funds. This
does not mean that SSA will approve as a reasonable fee 25 per
cent of the past-due benefits. The amount payable to the attorney or
eligible non-attorney 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
attorney or eligible non-attorney 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 attorney or eligible non-attorney and the client.
SSA will not pay a fee from withheld past-due benefits when the
authorized fee is for an attorney or non-attorney who was discharged
by the client or who withdrew from representing the client.

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
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
StatementPRA
- This information collection
SeeActRevised
meets the requirements of 44 U.S.C. § 3507, as amended by section 2
Statement
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. SEND THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE. To find the nearest office, call
1-800-772-1213 (TTY 1-800-325-0778). Send only comments on our
time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD
21235-6401.

Form Approved
OMB No. 0960-0104

TOE 850

SOCIAL SECURITY ADMINISTRATION

IMPORTANT
INFORMATION
ON REVERSE SIDE

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

PAPERWORK/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 section 206 of the Social Security Act (42 U.S.C.
406).

Fee $

I request approval to charge a fee of

(Show the dollar amount)

for services performed as the representative of
My Services Began:
Month

My Services Ended:

/
/

Day

/

Year

Type(s) of claim(s)

/

Enter the name and the Social Security number of the person on whose Social Security record the claim is based.

/

1.

2.

3.

/

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.
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.
(a) Have you received, or do you expect to receive, any payment toward your fee 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 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:

YES

NO

YES

NO

$
$

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?
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?
If "yes," what fee did you or will you charge for services in connection with the court proceedings?

YES

NO

YES

NO

$

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)
Telephone No. and Area Code

Firm with which associated, if any

[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 (2-2005) EF (12-2009)
Destroy Prior Editions

Telephone No. and Area Code

CLAIMANT'S COPY

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 Hearings and Appeals.
• 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 Hearings
and Appeals, Attention: Attorney Fee Branch, 5107
Leesburg Pike, Falls Church, VA 22041-3255.
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.

Form SSA-1560-U4 (2-2005) EF (12-2009)
Destroy Prior Editions

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.
The law and regulations 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 an attorney or a non-attorney whom SSA has
found eligible to receive direct payment. The amount SSA
may pay your attorney or eligible non-attorney 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 attorney or eligible
non-attorney 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 an attorney or non-attorney
representative if you discharged the representative or he or
she withdrew from representing you.

Form Approved
OMB No. 0960-0104

TOE 850

SOCIAL SECURITY ADMINISTRATION

IMPORTANT
INFORMATION
ON REVERSE SIDE

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

PAPERWORK/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 section 206 of the Social Security Act (42 U.S.C.
406).

Fee $

I request approval to charge a fee of

(Show the dollar amount)

for services performed as the representative of
My Services Began:
Month

My Services Ended:

/
/

Day

/

Year

Type(s) of claim(s)

/

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?
If "yes," please specify the amount on which you agreed, and attach a copy of the
$
agreement to this petition.

3.

(a) Have you received, or do you expect to receive, any payment toward your fee 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 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:

YES
and

NO

See attached
YES

NO

YES

NO

$
$

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?
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?
If "yes," what fee did you or will you charge for services in connection with the court proceedings?

YES

NO

YES

NO

$

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)
Telephone No. and Area Code

Firm with which associated, if any

[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 (2-2005) EF 12-2009)
Destroy Prior Editions

Telephone No. and Area Code

REPRESENTATIVE'S 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 attorney representative or non-attorney
representative whom SSA has found eligible to receive direct payment
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 attorney or non-attorney 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 "OHA 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 Hearings and Appeals. 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 the hearing 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.

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.
Form SSA-1560-U4 (2-2005) EF (12-2009)
Destroy Prior Editions

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
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 change 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 the
representative is an attorney or a non-attorney whom SSA has found
eligible to receive direct payment, and SSA awards the claimant
benefits under Title II or Title XVI of the Social Security Act. In
these cases, SSA generally withholds 25 percent of the claimant's
past-due benefits. Once the fee is approved, SSA pays the attorney or
the eligible non-attorney from the claimant's withheld funds. This
does not mean that SSA will approve as a reasonable fee 25 per
cent of the past-due benefits. The amount payable to the attorney or
eligible non-attorney 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
attorney or eligible non-attorney 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 attorney or eligible non-attorney and the client.
SSA will not pay a fee from withheld past-due benefits when the
authorized fee is for an attorney or non-attorney who was discharged
by the client or who withdrew from representing the client.

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
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. SEND THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE. To find the nearest office, call
1-800-772-1213 (TTY 1-800-325-0778). Send only comments on our
time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD
21235-6401.

See revised PRA

Form Approved
OMB No. 0960-0104

TOE 850

SOCIAL SECURITY ADMINISTRATION

IMPORTANT
INFORMATION
ON REVERSE SIDE

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

PAPERWORK/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 section 206 of the Social Security Act (42 U.S.C.
406).

Fee $

I request approval to charge a fee of

(Show the dollar amount)

for services performed as the representative of
My Services Began:
Month

My Services Ended:

/
/

Day

/

Year

Type(s) of claim(s)

/

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?
If "yes," please specify the amount on which you agreed, and attach a copy of the
$
agreement to this petition.

3.

(a) Have you received, or do you expect to receive, any payment toward your fee 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 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:

YES
and

NO

See attached
YES

NO

YES

NO

$
$

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?
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?
If "yes," what fee did you or will you charge for services in connection with the court proceedings?

YES

NO

YES

NO

$

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)
Telephone No. and Area Code

Firm with which associated, if any

[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 (2-2005) EF (12-2009)
Destroy Prior Editions

Telephone No. and Area Code

OHA 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 attorney representative or non-attorney
representative whom SSA has found eligible to receive direct payment
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 attorney or non-attorney 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 "OHA 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 Hearings and Appeals. 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 the hearing 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.

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.
Form SSA-1560-U4 (2-2005) EF (12-2009)
Destroy Prior Editions

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
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 change 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 the
representative is an attorney or a non-attorney whom SSA has found
eligible to receive direct payment, and SSA awards the claimant
benefits under Title II or Title XVI of the Social Security Act. In
these cases, SSA generally withholds 25 percent of the claimant's
past-due benefits. Once the fee is approved, SSA pays the attorney or
the eligible non-attorney from the claimant's withheld funds. This
does not mean that SSA will approve as a reasonable fee 25 per
cent of the past-due benefits. The amount payable to the attorney or
eligible non-attorney 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
attorney or eligible non-attorney 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 attorney or eligible non-attorney and the client.
SSA will not pay a fee from withheld past-due benefits when the
authorized fee is for an attorney or non-attorney who was discharged
by the client or who withdrew from representing the client.

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
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 See
Reduction
Act Statement
Revised
PRA - This information collection
meets the requirements of 44 U.S.C. § 3507, as amended by section 2
Statement
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. SEND THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE. To find the nearest office, call
1-800-772-1213 (TTY 1-800-325-0778). Send only comments on our
time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD
21235-6401.

SSA will insert the following revised Privacy Act Statement into the form
at its next scheduled reprinting:
Privacy Act Statement
Petition to obtain Approval of a Fee for Representing a Claimant before the Social
Security Administration
Sections 205, 1631(d)(1), and 1872 Social Security Act, as amended, authorizes us to
collect this information. The information you provide on this form is used to determine a
fair value for services you rendered to the claimant named below. Your response is
voluntary. However, failure to provide all or part of the requested information may affect
the amount you are requesting.
We rarely use the information provided on this form for any purpose other than for the
reasons explained above. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not
limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights
to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office, the General
Services Administration, the National Archives and Records Administration, and
the Department of Justice);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, and investigative activities necessary to
ensure the integrity and improvement of Social Security programs.
We may also use this information in computer matching programs. Computer matching
programs compare our records with those of other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a
person’s eligibility for Federally-funded or administered benefit programs and for
repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Records
Notices entitled, Attorney Fee File, (60-0003) Social Security Administration, Office of
Disability Adjudication and Review. These notices, additional information about this
form, and information regarding our programs and systems are available on-line at
www.socialsecurity.gov or at your local Social Security Office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.