Fill and Sign the Representation Agreement Template Form

SOCIAL SECURITY REPRESENTATION AGREEMENT This agreement is made on the       day of       , 20       , by and between       , herein referred to as Claimant, and       , herein referred to as Attorney; to-wit: W I T N E S S E T H 1. Claimant employs Attorney to represent Claimant as his attorney-at-law in a Social Security Disability claim and empowers Attorney to take such action as may be advisable in the judgment of Attorney, including the taking of judicial review. 2. In consideration of the services to be performed by the Attorney and it being the desire of the Claimant to compensate Attorney out of the proceeds of the litigation, it is agreed that if the Social Security Administration [SSA] favorably decides said claim[s], Claimant will pay Attorney a fee equal to the lesser of 25% of the past-due benefits resulting from said claim[s], or $4,000.00. If the SSA decision is unfavorable, Attorney will receive nothing. Claimant and Attorney understand that for a fee to be paid or collected, it must be approved by the SSA. 3. All cost, including, but not limited to cost for medical reports, filing fees, and consultations and examinations by experts, in connection with the cause of action shall be paid by Claimant. 4. Claimant understands that Social Security Past-Due Benefits are defined as the total amount of money to which the Claimant [and any auxiliary beneficiary(ies)] become[s] entitled through the month before the month SSA effectuates a favorable administrative determination or decision on the Social Security Claim[s] and that Supplemental Security Income (SSI) Past-Due Benefits are defined as the total amount of money for which the Claimant [and beneficiary(ies)] becomes eligible through the month SSA effectuates a favorable administrative determination or decision on the claim[s]. 5. Attorney makes no warranties as to the successful termination of the cause of action, and all expressions made by Attorney relative thereto are matters of Attorney's opinion only. 6. This Agreement comprises the entire contract between Attorney and Claimant. Claimant acknowledges receiving a signed copy of this agreement. 7. The laws of the state of Mississippi shall govern the construction and interpretation of this Agreement. IN WITNESS WHEREOF, Attorney and Claimant have executed this Agreement on the day and year stated above. __________________________________________________       , ATTORNEY __________________________________________________ CLAIMANT ADDRESS _______________________________________ _______________________________________ SS NUMBER       -       -         