UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF OKLAHOMA ___________________________________ Plaintiff(s) vs. ___________________________________ Defendant(s) Case Number: ______________________ CERTIFICATION OF NOTICE TO PLAINTIFF (Pursuant to an attorney's fee request under 42 U.S.C. §406(b)) Comes now Counsel for Plaintiff and certifies that the Plaintiff ___________________________________________ has been advised of the undersigned's request for attorney's fees under 42 U.S.C. §406(b) and has executed the attached "Notice to Plaintiff" form. Dated this ___ day of ________________________, 20___. _______________________________ Signature ________________________________ Printed Name ________________________________ Firm Name ________________________________ Address ________________________________ City State Zip Code ______________ Phone ______________ Fax ________________________________ Email Address Certification of Notice to Plaintiff American LegalNet, Inc. www.FormsWorkFlow.com CV-25 (1/14) UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF OKLAHOMA NOTICE TO PLAINTIFF Your attorney has requested an award of attorney fees to be paid out of your past due Social Security benefits. The Social Security Administration has withheld money from your past due benefits for this purpose. Your attorney has made a request for the Court to award the amount of $ . The Court will decide whether your attorney should be awarded all or a part of the fees he/she claims. In making that determination, the Court will consider the contract you signed with your attorney and the work performed to obtain your Social Security benefits and will determine whether the amount requested is reasonable. You must let the Court know whether you do, or do not, object to the amount of fees requested. If you object, you must give reasons for your objection. Please indicate below whether you do, or do not, object to an attorney fee award up to the amount requested by your attorney. Check only one box. I do not object to the attorney fees requested by my attorney. I do object to the requested fees for the following reason(s): Signature of Plaintiff Date Certification of Notice to Plaintiff 2 American LegalNet, Inc. www.FormsWorkFlow.com CV-25 (1/14) CERTIFICATE OF SERVICE I hereby certify that on _________________ (Date), I electronically transmitted the foregoing document to the Clerk of the Court using the ECF System for filing and transmittal of a Notice of Electronic Filing to the following ECF registrants (names only are sufficient): I hereby certify that on _________________ (Date), I served the same document by U.S. Postal Service Courier Service In Person Delivery E-Mail on the following, who are not registered participants of the ECF System: Names(s) and Address(es): ____________________________________ Signature Certification of Notice to Plaintiff 3 American LegalNet, Inc. www.FormsWorkFlow.com CV-25 (1/14)