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Get SSA-1560-U4 2017

Signature of Claimant Form SSA-1560-U4 03-2014 EF 03-2014 Destroy Prior Editions 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. Where to File the Petition 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. 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 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 YES If yes please specify the amount on which you agreed and attach a copy of the agreement to this petition* and NO See attached 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 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* 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 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 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.

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