Fill and Sign the Agreement between Client Form

Agreement between Certified Disability Advocate and Client Agreement made on the __________________ (date) , between ____________________ (Name of Advocate) of ____________________________________________________ ___________________________________ (street address, city, county, state, zip code), referred to herein as Advocate , and __________________ (Name of Client) , of ____________ _______________________________________________ (street address, city, county, state, zip code) , referred to herein as Client . For and in consideration of the mutual covenants contained in this Agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: 1. Advocate’s Fees A. Client hereby employs Advocate to represent Client before the Social Security Administration (SSA) in Client’s disability case. Client agrees that If Advocate wins at any administrative level through the first administrative law judge (ALJ) decision after the date of this agreement, Client agree that the attorney fee will be the lesser of twenty-five percent (25%) of all past-due benefits awarded to my family and me, or the dollar amount established pursuant to 42 U.S.C. § 406(a)(2)(A), which is currently $5,300, but may be increased from time to time by the Commissioner of Social Security. B. Client understands that Advocate has the right to seek administrative review to increase the amount of the fee set under the preceding sentence of this Agreement; but if that happens, Advocate will not ask for a fee of more than 25% of total back benefits awarded in Client’s case. If the first ALJ decision after the date of this Agreement is a denial and Advocate agrees to appeal and Client wins the case later, the fee will be twenty-five percent (25%) of all back benefits awarded in my case. If Client receive both social security disability and Supplemental Security Income (SSI) benefits, Client understand that the total fee will not be more than 25% of all past-due benefits, or no more than the limit set by 42 U.S.C. § 406(a)(2)(A), if the limit applies. C. Client and Advocate understand that if no benefits are obtained, then Advocate gets no fee. 2. Scope of Representation Client has employed Advocate to represent Client in Client’s Social Security disability and/or SSI claim. Client understands and agrees that Advocate does not represent Client in any other public or private claim related to Client’s disability, or with any other government agency or any insurance company unless separate arrangements, including a separate contract, have been made for representation on any other claim. 3. Payment of Advocate’s Fees Client understands and agrees that the Social Security Administration (SSA) will hold out 25% of past-due benefits and pay Client’s Advocate for his work on Client’s case unless Advocate waives withholding and direct payment. If Advocate waives withholding and direct payment or if SSA fails to withhold Advocate’s fees, Client will pay Advocate promptly from the any back benefits Client receives. 4. In addition to fees, Client agrees to pay Advocate for reasonable expenses that he pays in my case. These may include medical records and reports, photocopying, travel expenses, transcript preparation, and similar such expenses. Advocate agrees to supply a bill for expenses that shows how and when Advocate spent the money. In a case in which Client get benefits, Client agrees to pay Advocate back for these expenses as soon as Client gets a check for back benefits. Client agrees to pay expenses whether Client and Advocate win or lose. 5. No Representation the Client Will Win Client has not been promised that Client and Advocate will win, but Advocate has agreed to put forth his best efforts to help Client . 6. Client agrees to notify Advocate of any contacts, notices, or other correspondence sent to the Client by the Social Security Administration. 7. Fee on Discharge or Withdrawal If Client discharges Advocate or if as a result of Client failure to cooperate, commission fraud, misrepresentation, or other similar misconduct, Advocate withdraws from the prosecution of the above-stated claim, Client agrees to pay Advocate a reasonable fee computed SSA guidelines and regulations as well as any expenses advanced by Advocate . 8. No Waiver The failure of either party to this Agreement to insist upon the performance of any of the terms and conditions of this Agreement, or the waiver of any breach of any of the terms and conditions of this Agreement, shall not be construed as subsequently waiving any such terms and conditions, but the same shall continue and remain in full force and effect as if no such forbearance or waiver had occurred. 9. Governing Law This Agreement shall be governed by, construed, and enforced in accordance with the laws of the State of ______________. 10. Notices Any notice provided for or concerning this Agreement shall be in writing and shall be deemed sufficiently given when sent by certified or registered mail if sent to the respective address of each party as set forth at the beginning of this Agreement. 11. Mandatory Arbitration Any dispute under this Agreement shall be required to be resolved by binding arbitration of the parties hereto. If the parties cannot agree on an arbitrator, each party shall select one arbitrator and both arbitrators shall then select a third. The third arbitrator so selected shall arbitrate said dispute. The arbitration shall be governed by the rules of the American Arbitration Association then in force and effect. 12. Entire Agreement This Agreement shall constitute the entire agreement between the parties and any prior understanding or representation of any kind preceding the date of this Agreement shall not be binding upon either party except to the extent incorporated in this Agreement. 13. Modification of Agreement Any modification of this Agreement or additional obligation assumed by either party in connection with this Agreement shall be binding only if placed in writing and signed by each party or an authorized representative of each party. 14. Assignment of Rights The rights of each party under this Agreement are personal to that party and may not be assigned or transferred to any other person, firm, corporation, or other entity without the prior, express, and written consent of the other party. In this Agreement, any reference to a party includes that party's heirs, executors, administrators, successors and assigns, singular includes plural and masculine includes feminine. WITNESS our signatures as of the day and date first above stated. ________________________ _________________________ (P rinted name) (P rinted name) ________________________ __________________________ (Signature of Advocate) (Signature of Client) Social Security Number of Client_______________