Name: Ssa Fee Agreement Form: Pre-built template | airSlate SignNow
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Fill and Sign the Poms Gn 03940001 Fee Agreement Process Ssa Form

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FEE AGREEMENT THIS AGREEMENT is entered into pursuant to the Social Security Rules and Regulations pertaining to the fee agreement process. The law firm of _____________ , a professional law corporation engaged in the practice of law represented herein by the undersigned representative, and the undersigned claimant, who declared that they have entered into the following fee agreement. The undersigned representative is hereby engaged to pursue the claimant =s benefit rights in proceedings before the Social Security Administration. IN CONSIDERATION for the services rendered, the claimant agrees to pay to the representative a fee of _______ percent ( ____ %) of the claimant =s past -due benefits or $ _______ , whichever is less. Both parties herein understand t hat this fee is conditioned upon a favorable deci sion which would result in past -due benefits. T he parties both agree that in the event that the claim is unsuccessful there will be no fees due and owing to the representative. This fee agreement executed at _____________ , _______ Parish, Louisiana, on this _____ __ d ay of __________________, 20 ____ . _____________________________ CLAIMANT _____________ BY:__________________________ _____________

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