• me in my claim(s) Social Security Disability and/or Supplemental Security Income (SSI) benefits. This agreement shall apply to all stages of the application and appeals process with Social Security Administration.

    There is no fee unless I receive a favorable or partially favorable decision for my claim. The Firm has not promised that my case will result in a favorable decision. If I do not win any benefits, the Firm will not receive any fees. In the event I receive a favorable or partially favorable decision, I agree to have SSA pay the Firm the lesser of (a) 25% of any past due benefits awarded to me and my family or (b) 6,000 (or such higher limit set charged by the Commissioner of the SSA pursuant to 206 (a)(2) (A). I understand that SSA must approve any fee charged by my attorney for services provided in proceedings before the SSA. Claimant also understands and agrees that SSA will withhold the attorney fees from the payment of past due benefits, and SSA will pay such fees directly to the attorney. Under the Social Security Regulations, “past due benefits” include all benefits payable to claimants and/or their families/dependents.

    The maximum fee specified in the above paragraph applies if approval or favorable decision is obtained up to and including the Appeal Council level, however, if a favorable decision is obtained at the Federal level, the Attorney will file a fee petition with SSA, requesting Attorney’s fees be approved. If SSA does not approve this fee agreement, Attorney will submit a Fee Petition to the SSA for approval of a reasonable fee in accordance with applicable regulations.

    I agree to pay all expenses in connection with my case, or pay the attorney’s law firm back for any such expenses they pay. These expenses include but may not be limited to expenses charged by others, such as copying charges by third parties, fees from doctors for medical records or opinions, and shipping costs. I hereby give my “power of attorney” to Grant Kaplan and authorize them to request all medical records and sign all appeal documents on my behalf.

    I understand that SSA must approve any fee charged by Attorney for services provided in proceedings before the SSA. Claimant also understands and agrees that SSA will withhold the attorney fees from the payment of past due benefits, and SSA will pay such fees directly to the attorney.

    I understand that the Attorney reserves the right to withdraw from my case or that I may decide I no longer want the Attorney to represent me. In either case, I understand the attorney may nevertheless ask the agency to approve a fee for the attorney’s time and any expenses incurred. I understand that by hiring this law firm I am not guaranteed to win my case.

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