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Sample Fee Petition

Petition for Fee Approval

Claimant's name: _____________________ SSN _______ _____ _______
Date service began: ___________________
Date service ended: ___________________
Levels of service: (Initial, Recon, ALJ) __________________.
Case outcome: ____________________________________, for service rendered in the representation of above named client before the Social Security Disability Administration.

Itemization of Services:                                                                                              Hours

I. Client interview
   a) Discussion of service with client.
   b) Form completion
   c) Discussion of client's rights
   d) Discussion of client's impairments
   e) Client interview.                                                                       Total Hours: __________

2. Representative request to SSA and information letters to claimant and SSA.: ____________

3. File development, review of medical records, case summary and preparation of the case memorandum. These activities include but are not limited to case review of all available evidence for technical and medical issues involved in the case. Review of previous decisions, sequential and vocational analysis, RFC determination and preparation of all correspondence to claimant and SSA.

Total from above $: ________

4. Case control and client contacts: ____________.
5. Post decisional client consultation: ____________.
6. Face-to-Face with hearings officer or ALJ: _________.
7. Expenses to include: _________.
a) Total travel cost for SSA reimbursement: $ ________.
b) Mail, correspondence and phone costs: $ __________.

Total Fee charged $ ____________.

A copy of this fee summary petition has been sent to claimant as per SSA regulation 416. 1525a (7).

Representative Qualifications:

The authorized representative named below has been specifically trained in the review of the medical and vocational issues involved in Social Security disability claim. This individual has successfully completed the Disability Associates Consultant training program which involves thirty hours of dedicated training in the field of disability representation. This training has allowed for valuable assistance to this claimant's case as outlined in the SSA code of regulation 410.685 for non-attorneys.

( The above segment is also a good place for the representative to describe his formal or educational background. You may want to indicate any professional education or background such as a Nurse or Social Worker. SSA really likes to see this type of professional experience. If you do not have a professional background, don't worry about it).

Signature of
Authorized Representative.: _____________________________ Date: __________.

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