In consideration for legal services performed in connection with my application for Social Security benefits and/or Supplemental Security Income, if my claim is approved, I will pay the undersigned attorney(s) a fee in an amount equal to 25% of the retroactive benefits awarded to me and any auxiliary beneficiaries.
My undersigned attorney and I understand that one or both of us may request review of the fee amount, in writing, within 15 days after SSA has notified us of any amount my representative can charge. I agree that the undersigned may ask SSA to increase the fee, and I have been informed that she will do so if the claim is awarded, but the fee received is less than two thousand dollars ($2,000.00). The undersigned attorney may then file a fee petition with the Social Security Administration asking approval of a fee not in excess of Two Thousand dollars ($2,000.00). I understand that any affected auxiliary Social Security beneficiary or I may ask SSA to reduce the fee.
I further agree that I am responsible for out-of-pocket expenses incurred on my behalf. This includes, if any, costs medical providers may charge for providing necessary medical records, whether my claim is decided favorably or not. My attorney will notify me in advance of any such costs.