I-1-2-117.Exhibit - Fee Agreement Recommendation in Subsequent Application Case

Last Update: 9/9/04 (Transmittal I-1-47)

Claimant's Name __________________________________________

Claim Number ____________________________________________

Representative's Name ______________________________________

FEE AGREEMENT RECOMMENDATION

I reviewed any appointment of representative and fee agreement in both the prior and subsequent application files, and any fee agreement approval or disapproval in the subsequent application.

[Select all items that apply and check the basis or bases for the action, as necessary.]

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Signature

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Date