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EE_firw,§uC gxéimpw. , D.?J_em£.«_-,Q-: A_\rgml;7_£t_\&L_2nng_cy_€-_1Lké i‘Sn-mu__, p lr.\MC Darm.LN( f’hsr’J-‘p finch filfl‘Ovl’m 'lC/nfiqé’l Qrmlu Olen-Lw- 5.m 2180885194 * STATE OF CALIFORNIA DEPARTMENT 0F CORRECTIONS AND REHABILITATION r ' . ~ .v ; CDCR 128-3 (Re‘v. 4/74) NAMETJE‘NKIN'S‘ ‘ CDCR#: 3.17035 H0USING:CTFCEw-225u .. On Friday, April 23 2021, the Correctional Training Facility (CTF) Investigative Services Unit (ISU) received a '.‘r:_ph0ne call .from Aficia Jenkins. Alicia Jenkins stated she has been receiving unwanted and harassing phone _‘i"‘;calls from' Inmate Donald Jenkins BJ7035, Facility C EW-225U. Alicia J'enkihs explained she did not want to." :7 receive any_further written or telephonic communications from_Inmate Jenkins. 1: On April 29 2021 I spoke to Inmate Jenkins. I informed Jenkins l am ordering a Cease and Desist at the‘~- _r,equest of- Alicia Jenkins Therefore, I ordered Inmate Jenkins to have no contact with Alicia Jenkins This‘Is to ~' inclu’de Written verbal and telephonic communicatiOns. . "f,;vlnmate Jenkins was informed that if he disregards my order progressive disciplinary action wi||_ be taken and!" 1" "possnble legal action from the Monterey County District Attorney's Office. . . ‘ ‘ :l understand the orders give on this date: April 29,20%7W2-}; "-f-fg-S Mora,- Correct10na| Officer Investigative services Unit 3 “Correctional Tr'a_i_ni'ng Facility WWW LTflL +0 ev momnw lccm Made, “‘ ‘71 V9043 h Refit recorawxs Ckegmeé, 'Ahcxckts ‘H v7 {‘Q b‘OgK Sammie. Law her Tm mam 2L9 Lou +0 *' F€5PM¢ C96. :pé fag Cage LOOK (3+ PMS, 055%wmaamikwxmx.a&vr &w£%o giAmx 36mg 4/ grand, Law IS-e Says 77" RQWW-nwvvr be mamas, ‘ (UHMHf -511:»,PAT§.;:;4129/2021» ’ - CEASE AND oasis? 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On March 2CD“ ,ZQZI ,[D-XTE) [served the anached: Le'H-fir rficlfq)fl§+?ny gLSI-j: Recrfég (DESCRiBE DOCUMENT) 0n the parties herein by placing true and correct copies thereof, enclosed in a sealed envelope, wim postage thereon fiIHy paid, in the United States Mail in a deposit box so provided at the above-named correctional institution in “his h I am presentlv confined The envelope \v as addressed as FolHows: 30¢qu SQLUPE+7 &)v\-Q- '53 ngEA5>+ 3'0““) £6 5(U‘xnCL5, CA‘ ngGI [declarc under penafry ofperjury under the laws 0f the United States ofAmerica that tlwe foregoing ,is true and corr CL 9‘2! $77; Executed 0nW V/ Dlamflflmi #807035 (DATE) (DECLAKAMS SIG/‘JEJM :UDMA PCDOCS “ORDPERFECTIL'SZQ‘I Cn-O‘) [Rn 9 9?) 8133085 191;. ___._H,________n_ ZS whom _?*+.Mo~_,7. Cqmerm . 363$: 24 MY Mame.$5 DonqlA. 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P. 5; 33 U.S.C.§ 174(3) l, gong} d M Jenkins #BT70? S ,declarei lam over 13 years of age and a party to this action. lam a resident of C v 77p Soleécud ' ' (Q)41+6 Prison, inthecoumyor - MOrH-eféy . , Sm: ofcmiforgia. M» prison address ls 9 0 @ij (9%9 Somécxd. C A Q3399 O . 0n Mmk 1C0 8,02 l ,[DXTE) Iservedtheanached: L€++flr VeCh-{J&5~\~V§g )deH-ef Conmtx' In?TO ancL Demoné Cor Dowmen+ as Smallclcomb Courlr Regch-e(DEstRIBEDOCUXIENTi on the panies herein by ptacing true and correct copies thereof, enctosed m a sealed envelope, with pestage thereon fully paid, in [he United States Mail in 21 deposit box so provided at the above-named correctional institution in which l am presently confined. The envelope was addressed as follows: A ‘ ?cx‘o‘. Jen Kms 27/9 Mom“ Ri Rwepbmm‘C-P‘ °fSZ>Ln7- [declare under penalty ofperjury under the laws ofthe United States ofAmerica that [he foregoing ,is true and correct. W/Executed 0n S'ng’g I - ‘ gay /M» # 33-7035 (DATE) ' r‘smECLARAN SIVURE J CwG‘HRcv. 997) ::ODMA PCDOCS WORDPERFECTQESJE‘J u ‘ xAHICCU» 21S0085 194 fl" E’Zéwalz ‘LW_ _ .u- a "kw”. _,. u I 09% Véor km)er OJ/irAckCL n85 uff ALSO flea: £16m? Efbpé/Jéa- . :foRe_Q&/30o/MS_§L\[mLS/QQULL.7;“HLVW Q30 yo-OiwggLfitoigdecLL;LOlflxfitk-La4J gvmei QUJ- E R&d-f +Q File, 3/ A435 go‘mfl (55‘qu +m+ TALMM GLJIOLJELIJT Lap.) 1543+ 800% 1+5 /0_/' 0.00 QM CK- Alcckrrd 86360“ fix ba Sucigoc . ifgjftg Thaifl/ 4-: ogrgmmL/I__Qe¢32mé_ '- 750v? yam pow MLLmWomt Smewaw Oueqm flmeWQné. I Am ALSO , ' ' 3VDMEQ __Femm£xflefl_>efl+ Cm:- %Jw€_'~:-.'MMt/‘hs ,2;d_i¢ 0M“ remade. Mf#CAeLf§$_duL 4'0 yfinr/ ' . ‘ ‘/~l\SMooac,€me/)J' £95 MT ?Ct/reé/ tCsLJiyL/Lfi 7-27i07:u_- ;;brehyflfl‘Lflrm m 53;), oumpvmemi 'r/«e, Tbim @9pr1m Demaé “1.5 +56%M09: aflaugcé, 5; +}»e._._.LaLJ_ ”MW MW 15 M7 093mm! M03. QM ?fx mena‘ PNW +bfl MC Sumefi-M foim 5C IO_G 7L6 504+k/Clom - Qflfixm’ 00% 916?)" got” g\'\\/_\7 o .I\' r W741 ©x¢M¢ Cage. Tb Lefgcére- MOL-F-RQ igr Idorfi‘ }w€c(* 50:02.. a 180085 1%" e. +--_ gmmfy£u_fn t€?_cgc&>!“}u_‘}:}xg_§mcd l C @907Smyw mm Egg? “Sm Jew ‘17: LfiikL$_Qé_ML’tb3:5 Lfi‘H-U Gad {ECOSTL ‘95; 3mm“ 2'27 Mom mew: *;L__;cLemmL . ,1 , . ' I‘m bpmsv’m reboivfisvbkrs MmiW5-6uficlc- v / N ‘ ‘ fig” -Qe;or¥* bu} “AM - PficagmgvivLHU%ér_éc ‘ “$10k?” V _ . ___ ,_,#__ Qfiigrwg gélg__‘;r_e_+g_Lg}:.9.ong};_5,&:ouz_c__9‘_- i albuuuwcfi Emwr @ 5c__________a. ‘ INFORMATION FOR CLAIMANTS What a Representnt'ive May Do We will work directly with your appointed representative unless he or she asks us l0 work directly with you. Your representative may: ° get information from your claim(s) file; - with your pcrmissjqn, designate associates who perform administrative duties (c.g. clerks), partners and/or parties under contractual arrangements (c.g., copying services) to receive information from us on his 0r her behalf: By signing I this form, you are providing your permission for your representative to designate such associates, partners, and/or contractual parties, ' come with you, oeror you, t0 any interview, conference, or hearing you have with us; ' request a reconsideration, hearing, 0r Appeals Council review; and - help you and yogr witnesses prepare for a hearing and question any witnesses. Also, your representative will receive a copy oflhe decision(s) we make on'your claim(s). We will rclx 0n xour representative to tell vou about the stams of vour cja_im(s), but you still may call or visit us for information; You and your representative(s) are responsible for giving Social Security accurate information. It is wrong to knowingly and willingly furnish false information. Doing so may result inWm“- ww+wy¢5 We usually continue to work with yourlrepresemativc until (l) you notify us’ in writing that he 0r she n0 longer represents you; 0r (2) your representative tells us that he or she is withdrawing 0r indicates that his or her services have ended (for example, by filing a fee petition or not pursuing an appeal). We do not continue t0 work with someone who is suspended or disqualified from representing claimants. -% -_§ r-é r9 What Your Representative(s) May Charge Each representative you appoint can ask for a fee. To charge you a fee for services, your representative must get our approval. (Even when someone else will pay the fee for you, for example, an insurance company, your representative usually must get our approval.) One way is 10 file a fee petition. The other way is to file a fee agreement with us. 1n either case, your representative cannot charge you more than the fee am0unt we approve. lfhe or she does, promptly report this to your Social Security office. - Filing A Fee Petition Your representative may ask for approval ofa fee by giving us a fee petition when his 0r her work on your claim(s) is complete. This written request describes in detail the amount oftime he or she spent on each service provided you. The request also gives the amount oftlle fee the representative wants to charge for these services. Your representative must give you a copy ofthe fee petition and each attachment. Ifyou disagree with the information shown in the fee petition, contact your Social Security office. Please d0 this within 20 days of receiving your copy ofthe petition. We‘will review the petition and consider the reasonable value ofthe Services provided. Then we will tell you in writing the amount ofthe fee we approve. Form SSA-1 696-U4 (05-2008) ef (05-2008) gag? Alma - Filing A Fee Agreement Hp‘d'4fi’9 \ I\. Ifyou and your representative have a written fee ’TO BegomL agreement, one ofyou must give it t0 us before we decide your claim(s). We usually will approve the 19kae’ agreement ifyou both signed it; the fee you agreed on is no more than 25 percent ofpast-due benefits, or $5,300 (or a higher amount we set and announced in the Federal Register), whichever is less; we approve your claim(s); and your claim results in past-duc benefits. We will tell you in writing the amount ofthe fee your representative can charge based on the agreement. What Your Representative(s) May Charge, continued lfwe do not approve the fee agreement, wc will tell you and your representative in writing Then your representative must file a fee petition to charge and collect a fee. After we tell you the amount ofthc fee your representative can charge, you 0r your representative can ask us t0 look at it again ifeither or both ofyou disagree with the amount. (Ifwe approved a fee agreement, the person who decided your claim(s) also may ask us to lower the amount.) Someone who did not decide the amount 0fthe fee the first lime will review and finally decide the amount ofthe fee. How Much You Pay You never owc more than the fee we approve, except for: - any fee a Federal court allows for your representative's services before it; and - out-of-pocket expenses your representative incurs or expects lo incur, for example, the cost of getting your doctor's or hospital's records. Our approval is not nccdcd for such expenses. Your representative may accept money in advance as long as he or she holds it in a trust or'escrow account. We usually withhold 25 percent ofyour pasl-due benefits t0 pay toward the fee for you if: _ - your retirement, survivors, disabilty insurance, and/or supplemental security income claim(s) results in past-due benefits; - your representative is an attorney 0r a non-attomey participating in the direct fee payment project; and - your representative registers with us for direct payment before we effectuate a favorabie decision 0n your claim. You must pay your representative directly: - the rest 0fthe fee you owe ifthc amount ofthe fee is more than any amount(s) your representative held for you in a trust or escrow account and we withheld and paid your representative for you. ' - all ofthc fee you owe ifwe did not withhold past-duc benefits, fdr example, because your representative waived direct payment, or you discharged the representative, or the representative withdrew from representing you before wflc issued a favorable decision; 01f ifwe withheld, but later paid you the money because your representative did not either ask for our approval until after 60 days oflhc date ofyour notice of award or tell us on time that he or she planned to ask for a fee. " INFORMATION FOR REPRESENTATiVES 2 13 C 0 8 5 19 l} _ Fees For Representation An attorney or other person who wants to charge or coilect a fee for providing services in connection with a claim before the Social Security Administration must first obtain our approval of the fee for representation. The only exceptions are if the fee is for services provided: - when a nonprofit organization or government agency will pay the fee and any expenses from government funds and the claimant incurs no liability, directly 0r indirectly, for the cast(s); ' in an official capacity such as legal guardian, committee, or similar court-appointed office and 'lhe court has approved the fee m question; or - in representing the claimant before a coun of law. A representative who has provided services in a claim before both the Social Security Administration and a court of law may seek a fee from either or both, but neither tribunal has Lhe authority t0 set a fee for the other. Obtaining Approval OfA Fee ' To charge a fee for Services, you must use one oftwo, mutually exclusive fee approval processes. You must file either a fee petition or a fee agreement with us. In either case, you cannot charge more than the fee amount we approve. o Fee Petition Process You may ask for approval ofa fee by giving us a fee petition when you have completed your services t0 the claimant. This written request must describe in detail the amount of time you spent on each service provided and the amount of the fee you are requesting. You must give lhc claimant a copy 0f the fee petition and each attachmem. The claimant may disagree with the information shown by contacting a Social Security office within 20 days of receiving his or her copy ofthe fee petition. We will consider the reasonable value ofthe services provided, and send you notice ofthc amount ofthc fee you can charge. ° Fee Agreement Process Ifyou and the claimant have a written fee agreement, either ofyou must give it Io us before we decide the claim(s). We usually will approve the agreement ifyou both signed it; the fee you agreed on is no more than 25 percent of past-duc benefits, or $5,300 (0r a higher amount we set and announced in the Federal Register), whichever is less; we approve the claim(s); and the claim results in past-duc benefits. We will send you a copy of the notice we send the claimant telling him or her the amount ofthe fee you can charge based on the agreement. ' If we do not approve the fee agreement, we will tell you in writing. We also will tell you and the claimant that you must file a fee petition ifyou wish to charge and collect a fee. After We tell you the amount ofthc fee you can charge, you 0r the claimant may ask us in writing to review the approved fee. (Ifwc approved a fee agreement, the person who decided the claim(s) also may ask us to lower the amount.) Someone who did not decide the amount ofthe fee the first time will review and finally decide the amount ofthe fee. Form SSA-1 695-U4 (05-2008) ef (05-2008) Collecting A Fee You may accept money in advance, as long as you hold it in a trust or escrow account. The claimant never owes you more than the fee we approve, except for: - any fee a Federal court allows for your services before it; and ° Out-of-pocket‘ expenses you incur or expect to incur, for example, the cost ofgetting evidence. lfvou are not an anomev and vou are ineligible to receive direct payment, you must collect the approved fee from the claimant. Ifyou are interested in becoming eligible t0 receive direct payment, you can find information 0n the procedures for becoming eligible for direct payment on our "Representing Claimants" website: hth/wwwssa,Eov/reoresentatiom’. lfvou are an attomev or a non-attornev whom SSA has found eligible t0 receive direct payment. we usually withhold 25 percent of any past-due benefits that result from a favorably decided retirement, survivors, disability insurance, or supplemental security income claim. Once we approve a fee, we pay you all or part 0fthe fee from the funds withheld. We will also charge you the assessment required by section 206(d) and 163 l(d)(2)(C) 0fthe Social Security Act. You cannot charge or collect this expense from the claimant. You must collect from the claimant: - the rest he or she owes ifthe amount ofthe fee is more than the amount ofmoney we wi_thheld and paid you for the claimant, and any amount you held for the ' claimant in 'a trust 0r escrow account. - all ofthe fee he 0r she owes ifwe did not withhold past-due benefits, for example, because there are n0 past-due benefits, or the claimant discharged you, or you withdrew from representing the claimant; 0r if we withheld, but later paid the money to the claimant because you did not either ask for our approval until after 6O days 0fthe date ofthe notice of award 0r tell us on time that you planned t0 ask for a fee‘ Conflict Of Interest And Penalties For improper acts, you can be suspended or disqualified from representing anyone before the Social Security Administration You also can face criminal prosecution. Improper acts include: - Ifyou are or were an officer 0r employee oflhc United States, providing services as a representative in certain claims against and other matters affecting the Federal government. - Knowingly and willingly furnishing false information. - Charging or collecting an unauthorized fee or too much for services provided in any claim, including services before a court which made a favorable decision. References ' 18 U.S.C. §§203, 205, and 207; and 42 U.S.C. §§406(a), 1320a-6, and 1383(d)(2) - 20 CFR §§404.l700 et. seq. and 4 16.1500 et. seq. - Social Security Rulings 88-10c, 85-3, 83-27, and 82-39 ' 26 U.S.C. §§ 6041 and 6045(1) u Chioosing To Be Represented You can choose to have a representative help you when you d0 business with Social Sepurity. We will work with your representative,just as we-would with you. It is important that you select a qualified person because, once appointed, your representative may act for you in most Social Security matters. We give more information, and examples of what a representative may d0, 0n the back 0fthe "Claimant's Copy" of this form. Privacy Act Notice Sections 206(a) and 163 I(d) ofthe Social Security Act authorize the collection of information on th}s form. Providing the information is voluntary. However, ifyou want t0 appoint someone t0 act on your bchalfin matters before [he Social Security Administration, then you and that individual must complete-lhc appropriate sections ofthis form. The information-is needed to verify your appointment 0fthe individual as your representative and his/her acceptance 0f the appointment. We may provide information collected on this form to another Federal, Stale, or local government agency t0 assist us in verifying any infomiation you provide, 0r ifa Federal law requires the release of information. We may also use the information you give us when we match records with those 0f other Federal, State, or local government agencies. The law allows us to do this even if you do not agree to it. With your permission, your representative may designate an associate or other party to request and receive information from your claim file on your representative's behalf. Information about these and other reasons why any information you provide us may be used or given out is available in any Social Security office. Ifyou want to learn more about this, cantact any Social Security office. How To Complete This Form Please print 0r type‘ At the top, show your full name and your Social Security number. Ifyour claim is based on another person‘s work and earnings, also show the "wage eamer's" name and Social Security number. Ifyou appoint more than one person, you may want t0 complete a form for each ofthem. Part I Appointment ofRepresentative Give the name and address ofthe person(s) you arc appointing. You may appoint an attorney 0r any other qualified person to represent you. You also may appoint more than one person, but see "What Your Representativc(s) May Charge" on the back ofthe "Claimant's Copy" ofthis form‘ You can appoint one or more persons in a firm, corporation, 0r other organization as your rcpresentativc(s), . but you max n91 appdint a law firm, legal aid group, comozation, or organization itself. Check the block(s) showing the program(s) under which you have a claim. You may check more than one block. Check: ° Title [I (RSDI), ifyour claim concerns retirement, survivors, or disability insurance benefits. - Title XVI (SSI), ifyour claim concerns supplemental security. income. Form SSA-1 696-U4 (05-2008) ef (05-2008) . COMPLETING THIS FORM TO APPOINT A REPRESENTATIVEE 1 S C 0 8 5 1 9 4 ° Title XVIII (Medicare Coverage), ifyour claim cancems entitlement to Medicare 0r enrollment in the Supplementary Medical Insurance (SMI) plan. Ifyour representative has your permission to designate an associate, such as a clerk, other party, 0r entity, such as a copying service, t0 receive information for him or her from us about your claim(s), check the block to authorize this release. Ifyou will have more than one representative, check the block and give the name ofthe person you want t0 be the main representative. Sign your name, but prim 0r type your address, your area code and telepllone'number, and the date. Ifyou are appointing a representative to replace a representative you discharged or who withdrew from representing you, you must notify us in writing that the prior appointment has ended. Part II Acceptance of Appointment Each person you appoint (named in part I) completes this 'parl, preferably in all cases. If the person is not an attorney, he or she mm; give his or her name, state that he or she accepts the appointment, and sign the form. Part III (Optional) Waiver 0f Fee Your representative may complete this part ifhe or she will not charge any fee for the services provided in this claim. Ifyou appoint a second representative or co-counsel who also will not charge a fee, he 0r she also should sign this part 0r give us a separate, written waiver statement. Part IV (Optional) Waiver of Direct Payment by an Attorney or a Non-Attorney Participating in the Direct Payment Project Your representative may complete this part ifhe 0r she is an attorney or a non-altomey who does not want direct payment ofall or pan of the approved fee from pasl-due retirement, survivors, disability insurance, or supplemental security income benefits withheld. Paperwork Reduction Act Statement - This information collection meets the clearance requirements of 44 U.S.C. §3507, as amended by Section 2 ofthe Paperwork Reduction Act of I995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will lake about IO minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U.S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send commems on our time estimate above Io: SSA, 640/ Securizy Bozdevard, Balrimore, MD 21235-6401. Sendm comments relating r0 our time estimate t0 this address, not the completedform. References ' 18 U.S.C. §§203, 205, and 207; and 42 U.S.C. §§ 406(3), 13203-6, and 1383(d)(2) ' 20 CFR §§404. 1700 ct. seq. and 416.1500 et. seq. ' Social Security Rulings 88-10c, 85-3, 83-27, and 82-39 - 26 U.S.C. §§ 6041 and 6045(0 Social Security Administration 2 1 S C U 8 5 19 l} Form ApprovedPlease read the instructions before completing this form. 0MB No. 0950-0527 Name (Claimant) (Print or Type) SociaI Security Number b Wage Earner (If Different) SOCia' Security Number Partl APPOINTMENT OF REPRESENTATIVE | appoint this person, - ‘ . . _ "(Name ano AcareSS) to act as my representative 1n connection wnth my clalm(s) or asserted right(s) under; fl Title H E Title XVI me xv.“ D Title vm ‘ (RSDI) (SSI) (Medicare Coverage) (SVB) Thls person may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s). | authorize the Social Security Administration t0 release information about my pending claim(s) or asserted right(s) to designated associates who perform administrative duties (e.g. clerks), partners. and/or parties under contractual arrangements (e.g. copying services) for or with my representative. | appoint. or | now have. more than one representative. My main representative ts (Name of Principal Representative) Signature (Claimant) Address T(elephoge Number (with Area Code) Fax Number (with Area Code) Date _ ( ) _ Part ll ACCEPTANCE OF APPOINTMENT I, , hereby accept the above appointment. | certify that | have not been suspended or prohibited from practice before the Social Security Administration: that | am not disqualified from representing the claimant as a current or former officer or employee of the United States; and that i will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to on the reverse side of the representative‘s copy of this form. If | decide not to charge or collect a fee for the representation, | will notify the Social Security Administration. (Completion 0f Part ll satisfies this requirement) Check one: E l am an attorney. E I am a non-attorney who is participating in the direct fee payment demonstration project. U l am a non-attorney . | am not participating In the direct fee payment demonstration project. l have been disbarred or suspended from a court or bar t0 which | was previously admitted to practice as an attorney. D Yes E N0 | have been disqualified from participating in 0r appearing before a Federal program or agency. Yes No ldeclare under penalty of perjury that | have examined all the information on this form, and on any accofnpanying statements or forms, and it is true and correct to the best of my knowledge. Signature (Representative) ' Address Telephone Number (with Area Code) Fax Number (with Area Code) Date ( ) - ( ) - Part m (Optional) WAIVER OF FEE I waive my right to charge and collect a fee under sections 206 and 1631(d)(2) of the Social Security Act. I release my client (the claimant) from any obligations, contractual or otherwise, which may be owed to me for services I have provided in connection with my client's claim(s) or asserted right(s). Signature (Representative) Date Part N(Optional) WAIVER 0F DIRECT PAYMENT by Attorney or Non-Attorney Eligible to Receive Direct Payment | waive only my right t0. direct payment of a fee from the withheld past-due retirement, survivors. disability insurance or supplemental security income benefits of my client (the claimant). | do not waive my right to request fee approval and to collect a fee directly from my client 0r a third party. Signature (Representative Waiving Direct Payment) Date Form SSA-1696-U4 (05-2008) ef (05-2008) TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS Destroy Prior Editions (4 Copies: File. Claimant, Representative, ODAR) INFORMATION,FOR REPRESENTATIVES Fees For Representation An attorney or other person who wants to charge 0r collect a fee for providing services in connection with a claim before the Social Security Administration must first obtain our approval of the fee for representation. The only exceptions are ifthc fee is for services provided: - when a nonprofit organization or government" agency will pay the fee and any expenses from government funds and the claimant incurs no liability, directly or indirectly, for the cost(s); ' in an official capacity such as legal guardian, committee, or similar court-appointed office and the court has approved the fee in question; 0r - in representing the claimant before a court of law. A representative who has provided services in a claim before both the Social Security Administration and a court oflaw may seek a fec‘from either 0r both, but neither tribunal has the authority t0 set a fee for the other. Obtaining Approval OfA Fee T0 charge a fee for services, you must use one oflwo, mutually exclusive fee approval processes. You must file either a fee petition or a fee agreement with us. In either case, you cannot charge more than the fee amount we approve. - Fee Petition Prgcess You may ask for approval ofa fee by giving us a fee petition when you have completed your services t0 the claimant. This written request must describe in detail the amount oftime you spent on each service provided and the amount of the fee you are requesting. You. must give the claimant a copy ofthe fee petition and each attachment. The claimant may disagree with the information shown by contacting a Social Security office within 20 days of receiving his or her copy ofthe fee petition. We will consider the reasonable value 0fthc services provided, and send you notice ofthe amount ofthe fee y0u can charge. ° Fee Agreement Process Ifyou and the claimant have a written fee agreement, either ofyou must give it to us before we decide the claim(s). We usually will approve the agreement ifyou both signed it; the fee you agreed on is no more than 25 percent ofpast-due benefits, or $5,300 (or a higher amount we set and announced in the Federal Register), whichever is less; we approve the claim(s); and the claim results in past-due benefits. We will send you a copy of the notice wc send the claimant telling him or her the amount ofthe fee you can charge based 0n the agreement. Ifwe do not approve the fee agreement, we will tell you in writing. We also will tell you and the claimant that you must file a fee petition ifyou wish to charge and 'collect a fee. After we tell you the amount ofthe fee you can charge, you or the claimant may ask us in writing to review the approved fee. (lfwe approved a fee agreement, the person who decided the claim(s) also may ask us to lower the amount.) Someone who did not decide the amount ofthe fee the first time will review and finally decide the amount 0fthe fee. Form SSA-1 696-U4 (05-2008) ef (05-2008) 213008§19g Collecting A Fee I ~ You may accept money in advance, as long as you hold it in a trust or escrow account. The claimant never owes you more than the fee we approve, except for: - - any fee a Federal c0urt allows for your services before it; and - out-of-pocket expenses you incur or expect t0 incur, for example, the cost ofgetting evidence. lfvou arc not an attomev and vou are ineligible to receive direct payment, you must collect the approved fee from the claimant. Ifyou are interested in becoming eligible to receive direct payment, you can find information on the procedures for becoming eligible for direct payment on our "Representing Claimants" website: http:#wwwssaaov/representationh lfyou arc an attomeLor a non-attomeuvhom SSA has found eligible to receive direct Damenthe usually withhold 25 percent 0f any past-due benefits that result from a favorably decided retirement, survivors, disability insurance, or supplemental security income claim. Once we approve a fee, we pay you all 0r part 0fthe fee from the funds withheld. We will also charge you the assessment required by section 206(d) and l631(d)(2)(C) 0fthe Social Security Act You ' cannot charge or collect this expense from the claimant. You must collect from the claimant: - the rest he 0r she owes ifthe amount ofthe fee is more than the amount ofmohey we withheld and paid you for the claimant, and any amount you held for the claimant in a trust 0r escrow account. - all ofthe fee he 0r she Owes ifwc did not withhold past-due benefits, for example, because there are no past-due benefits, or the claimant discharged you, or you'withdrew from representing the claimant; or if we withheld, but later paid the money to the claimant because you did not either ask for our approval until after 60 days ofthe date ofthe notice 0f award or tell us on time that you planned to ask for a fee. Conflict Of Interest AndPenalties For improper acts, you can be suspended or disqualified from representing anyone before the Social Security Administration. You also can face criminal prosecution. Improper acts include: - Ifyou are 0r were an officer or employee ofthe United States, providing services as a representative in certain claims against and other matters affecting the Federal government. - Knowingly and willingly furnishing false information. ' Charging 0r collecting an unauthorized fee or too much for services provided in any claim, including services before a court which made a favorable decision. References - 18 U.S.C. §§203, 205, and 207; and 42 U.S.C. §§406(a), 13203-6, and l383(d)(2) ° 20 CFR §§404. 1700 et. seq. and 416.1500 et. seq. - Social Security Rulings 88-100, 85-3, 83-27, and 82-39 ° 26 U.S.C. §§ 6041 and 6045(f) ’ 2 ° I INFORMATION FOR CLAIMANTS g What a Representative May Do We will work directly with your appointed representative unless he or she asks us to work directly with you. Your representative may: ' ° get information from your claim(s) file; - with your permission, designate associates who perform administrative duties (e.g. clerks), partners andlor panics under contractual arrangements (c.g., copying services) t0 receive information from us 0n his or her behalf; By signing lhis form, you arc providing your permission for your representative to designate such associates. partners, and/or contractual parties, - come with you, or for you, to any interview, conference, or hearing you have with us; - ’request a rcconsideratioa, hearing, or Appeals Council review; and - help you and your witnesses prepare for a hearing and question any witnesses. Also, your representative wiII receive a copy OfIhe decision(s) we make on y0ur claim(s). We will rely on your representative to tell you about the status ofyour claim(s), but you still may call or visit us for information. You and your representativds) are responsible for giving Social Security accurate information It is wrong to knowingly and willingly furnish false information Doing so may result m criminal prosecution. We usually continue to work with your representative until (l) you notify us in writing that he 0r she n0 longer represents you; or (2) your representative tells us that he or she is withdrawing 0r indicates that his or her services have ended (for example, by filing a fee_petition or not pursuing an appeal). We do not continue to work with someone who is suspended 0r disqualified from representing claimants. What Your Representative(s) May Charge Each representative you appoint can ask for a fec To charge you a fee for services, your representative must get our approval. (Even when someone els¢ will pay the fee for you, for example, an insurance company, your reprcséntative usually must get our approval.) One way is to file a fee petition. The other way is t0 file a fee agreement with us. In either case, your representative cannot charge you more than the fee amount wc approve. If he or she does, promptly report this to your Social Security office. ° MgAFW-Petition. Your representative may ask for approval ofa fee by giving us a fee petition when his or her work on your ‘ claim(s) is complete. This written request describes in detail the amount oftime he or she spent on each service I provided you. The request also gives the amount ofthe fee 7 . the representative wants to charge for these services. Your representative must give you a copy ofthe fee petition and each attachment, Ifyou disagree with the information shown in the fee petition, contact your Social Security office. Please do this within 20 days of receiving your copy OfIhe petition. We will review the petition and consider the reasonable value ofthe services provided. Then we will tell you in writing the amount ofthe fee we approve. Form SSA-1 696-U4 (05-2008) ef (05-2008) What Your Representative(s) continued ' m; Ifyou and your representative have a written fee agreement, one 0f you must give it t0 us before we decide your claim(s). We usually will approve the agreement ifyou both signed it; the fee you agreed on is no more than 25 percent of past-due benefits, or $5,300 (0r a higher amount we set and announced in the Federal Register), whichever is lesg; we approve your c1aim(s); and your claim results in past-due benefits. We will tell ‘ you in writing the amount 0fthe fee your representative can charge based on the agreement. ay“Charge, Ifwe do not approve the fee agreement, we will tell you and your representative in writing. Then your representative must file a fee petition t0 charge and collect a fee. Afier we tell you the amount ofthe fee your representative can charge, you 0r your reprcséntative can ask us to look at it again ifcither or both ofyou disagree with the amount. (Ifwe approved a fee agreement, the person who decided your claim(s) also may ask us t0 lower the amount.) Someone who did not decide the amount orthe fee the first time will review and finally decide the amount 0fthe fee. How Much You Pay You never owe more than the fee we approve, except for: - any fee a Federal court allows for your representative's services before it; and - out-of-pocket expenses your representative incurs 0r expects to incur, for example, the cost 0f getting your doctor‘s or hospital's records. Our approval is n01 needed for such expenses. Your representative may accept money in advance as long as he or she holds it in a trust or escrow account. We usually withhold 25 percent ofyour past-due benefits to pay toward the fee for you if : - your retirement, survivors, disabilty insurance, andfor supplemental security income claim(s) results in past-due benefits; - your representative is an attorney or a non-attomey participating in the direct fee payment project; and - your representative registers with us for direct payment before we effectuate a favorable decision on your claim. You must pay your representative directly: ° the rest ofthe fee you owe ifthe amount ofthc fee is more than any amount(s) your representative held for you ina trust 0r escrow account and we withheld and paid your representative for you. ' all ofthe fee you owe ifwc did not withhold past-due benefits, for example, because your representative waived direct payment, or you discharged the representative, or the representative withdrew from representing you bcforc we issued a favorable decision; or ifwc withheld, but later paid you the money because your representative did not either ask for our approval until after 60 days ofthe date of'your notice ofaward 0r tell us on time that he or she planned t0 ask for a fee. 0085 9& COMPLETING THIS FORM T0 APPOINT A REPRESENTATIVE 2 1 S C 8 8 5.1 Choosing To Be Represented‘ You can choose to have a representative help you when you do business with Social Security. We will work with your representative,just as we would with you. It is important that you select a qualified pchOn because, once appointed, your representative may act for you in most Social Security matters. We give more infomation, and examples of what a representative may do, 0n the back ofihe, "Claimant's Copy“ of this form. _ ‘- Privacy Act Notice Sections 206(3) and 163 I(d) ofthe Social Security Act authorize the collection ofinformation on this form. Providing [he information is voluntar'y. However, ifyou want to appoint someone to act on your bchalfin matters before the Social Security Administration, then you and that individual must complete the appropriate sections of this form. The information is needed to verify your appointment ofthe individual as your representative and his/her acceptance 0fthe appointment. We may provide information collected 0n this form to another Federal, State, or local government agency to assist us in verifying any information you provide, 0r ifa Federal law requires the release ofinfonnation. We may aiso use the informatiOn you give us when we match records with those ofother Federal, State, or local government agencies. The law allows us t0 d0 this even ifyou d0 not agree to it. With your permission, your representative may designate an associate or other party lo request and receive information from your claim file on your representative's behalf. Information about these and other reasons why any information you provide us may be used or given out is available in any Social S'ecurity office. If you want to learn more about this, contact any Social Security office. How To Complete This Form Please print 0r type. At the lop, show your full name and your Social Security number. Ifyour claim is based on another person's work and earnings, also show the "wage earner‘s" name and Social'Sccurity number. Ifyou appoint more than one person, you may want to complete a form for each 0fthem. Part l Appointment 0f Representative Give the name and address 0fthe person(s) you are appointing. You may appoint an attorney or any other qualified person to represént you. You also may appoint more than one person, but see "What Your Representativc(s) May Charge" on the back ofthe "Claimant's Copy" ofthis form. You can appoint one 0r more persons in a firm, corporation, or other organization as your representativc(s), but mu may not appoint a law firm. legal aid group. comorggion or grganization itself. Check the block(s) showingthc program(s) under which you have a claim. You may check more than one block‘ Check: - Title II (RSDI), ifyour claim concerns retirement, survivors, 0r disability insurance benefits. ° Title XVI (SSI), ifyour claim concerns supplementaI security income. Form SSA-1696-U4 (05-2008) ef (05-2008) 94 - Title XVII] (Medicare Coverage), ifyour claim V concerns entitlement to Medicare or enrollment in lhc Supplementary Medical Insurance (SMI) plan. Ifyour representative has your permission to designate an associate, such as a clerk, other party, 0r entity, such as a copying service, t0 receive information for him or her from us about your claim(s), check the block to authorize this release Ifyou will have more than one representative, check the block and give the name ofthc person you want to be the main representative. Sign your name, but print 0r type your address. your area code and teleph0ne number, and the date. Ifyou are appointing a representative to replace a representative you discharged 0r who withdrew from representing you, you must notify us in writing that the prior appointment has ended. Part II Acceptance of Appointment Each person you appoint (named in pan l) completes this pan, preferably in all cases. lfthe person is not an auomey, he or she mug; give his or her name, state that he or she accepts the appointment, and sign the form. Part III (Optional) Waiver of Fee Your representative may complete this part ifhe 0r she will n01 charge any fee for the services provided in this claim. Ifyou appoint a second representative 0r co-counsel who also will not charge a fee, he or she also should sign this part or give us a separate, written waiver statement Part 1V (Optional) Waiver 0f Direct Payment by an Attorney or a Non-Attorney Participating in the Direct Payment Project " Your representative may complete this part ifhe or she is an attorney 0r a non-attomcy who does not want direct payment ofall or part ofthe approved fee from past-due retirement, survivors, disability insurance, 0r supplemental security income benefits withheld. Paperwork Reduction Act Statement - This information collection meets the clearance requirements of 44 U.S.C. §3507, as amended by Section 2 OfIhCBW Reduction Act 0f l 995. You d0 not need t0 answer these questions unless we display a valid Office 0f Management and Budget control number. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM T0 YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U.S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above r0: SSA, 640] Security Boulevard, Bahimore, MD 21235-6401. Semim comments relating r0 our time estimate to rlu's address, no! the completedform. References - 18 U.S.C. §§203, 205, and 207; and 42 U.S.C. §§ 406(a), 1320a-6, and 1383(d)(2) - 20 CFR §§404. 1700 ct. seq. and “6.1500 et. seq. ' Social Security Rulings 88-10c, 85-3, 83-27, and 82-39 - 26 U.S.C. §§ 6041 and 6045a) Social Security Administration Q I" 19 ll. Pleasie read the instructions before completing this form. a 1 U U U 8 5 E ' Name (Claimant) (Print orType) Social Security Number Form Approved OMB No. 0960-0527 Wage Earner (If Different) Social Security Number APPOINTMENT OF REPRESENTATIVEPart I | appoint this person, I I h I (Name and Address; to act as my representative In connection With my claim(s) 0r asserted right(s) under: g Title n E Title XVI D Title xvm U Title VIII (RSDI) (SSI) (Medicare Coverage) (SVB) This person may. entirely 1n my place make any request or give any notice; give or draw out evidence or Information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s ) ! | authorize the Social Security Administration to release information about my pending claim(s ) or asserted right(s) to designated associates who perform administrative duties (e.g. cierks), partners; andlor parties under contractual arrangements (e g copying services) for or with my representative. | appoint orl now have more than one representative. My main representative is (Name of Principal Representative) AddressSignature (Claimant) Fax Number (with Area Code) Date ( ) - Part ll ACCEPTANCE OF APPOINTMENT l hereby accept the above appointment. l certify that l have not been suspended or prohibited from practice before the Scolal Security Administratlon; that | am not disqualified from representing the claimant as a current or former officer or empioyee of the United States; and that | will not charge 0r collect any fee for the representation even If a third party will pay the fee unless it has been approved in accordance with the laws and rules referred to on the reverse side of the representative's ccpy of this form. Ifl decide not to charge or collect a fee for the representation. l will notify the‘Social Security Administration. (Completion of Part || satisfies this requirement. ) Check one: II am an attorney D I am a non-attorney who Is participating in the direct fee payment - demonstration project T(e~|ephor)1e Number (with Area Code) El am a non-attorney 1 am not participating In the direct fee payment demonstration project I have been disbarred or suspended from a court or bar to which Iwas previously admitted to pract+ce as an attorney. D Yes D N0 | have been disqualified from participating in or appearing before a Federal program or agency E Yes E No Ideclare under penalty oflperjury thatl have examined all the Information on this form and on any accompanying statements or forms. and tls true and correct to the best of my knowledge. Signature (Representative) Address Telephone Number (with Area Code) ( ) - Fax Number (with Area Code) ( ) - Date Part III (Optional) WAIVER OF FEE l waive my right to charge and collect a fee under sections 208 and ‘1631(d)(2) of the Social Security Act. | release my client (the claimant) from any obligations, contractual or otherwise, which may be owed to me for services 1 have provided in connection with my client's claim(s) or asserted right(s). Signature (Representative) Date Part lV (Optional) WAIVER OF DIRECT PAYMENT by Attorney or Non-Attorney Eligible to Receive Direct Payment l waive only my right to direct payment of a fee from the withheld past-due retirement. survivors, disability insurance or supplemental security income benefits of my client (the claimant). l do not waive my right to request fee approval and to collect a fee directly from my client or a third party. Signature (Representative Waiving Direct Payment) Date Form SSA-1 696-U4 (05-2008) ef (05-2008) Destroy Prior Editions TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS (4 Copies: File. Claimant. Representative, ODAR)
