Fillable Form SSA-1696 (02-2020) UF: Instructions for Completing Form

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Form SSA-1696 (02-2020) UF: Instructions for Completing Form

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Form SSA-1696 (02-2020) UF
Discontinue Prior Editions
Social Security Administration
Instructions for Completing Form SSA-1696
Page 1 of 6
OMB No. 0960-0527
Keep a copy of this form for your records
DO NOT FILE form SSA-1696 if you do not have a claim, you are not filing a claim with this form, or there is no other
issue pending decision with us. In this document, “you” means the claimant, beneficiary, auxiliary or spouse. “Us” and “SSA”
means the Social Security Administration.
General Information About This Form
• You have the right to appoint a qualified representative of your choice to represent you on any claim or asserted right under any
of our programs. For more information on who can qualify to be an appointed representative, when your representative's
appointment begins or ends, payment of fees to appointed representative(s), and other helpful information, or to locate your local
field office, you can visit our website at www.ssa.gov/locator
. Call us, toll-free, at 1-800-772-1213.
• You and your representative(s) may use this form to start the representation. Your representative may also use this form to
waive a fee, waive direct payment of the fee, or tell us that a third party will pay the fee.
• You may also choose to be unrepresented. We handle your case in the same manner whether you are represented or
unrepresented. You do not need to appoint someone who simply helps you through the process. For example, you do not need
to appoint someone who helps you come to our office, reads to you from documents, or interprets for you if you speak another
language. You only need to appoint someone if he or she will be acting or appearing on your behalf, or will be making decisions
about your case for you.
• You and your representative(s) must give us accurate information as quickly as possible. Providing misleading or false evidence
on this form or your application, or withholding or delaying giving us evidence, could lead to possible criminal charges or
administrative sanctions against you or your representative.
Appointing a Representative
If you are using this form to appoint a representative, you must complete Sections 1, 2, and 3. Your representative must complete
Sections 5 and 7 of this form. Both you and your representative must complete Section 4, either of you can complete section 6.
You or your representative must file the completed form with us, in-person at your local field office, by mail, or by fax. Review and
complete all required sections. If you are appointing multiple representatives, use separate forms for each representative. Your
representative or someone else can help you complete the form but you must sign and date Section 8. Your representative must
also sign the form if he or she is a non-attorney. You or your representative must submit the completed form to us before we will
recognize your representative. You can file it in-person at your local field office, mail it, or fax it to us. Do not file this form with your
local State Disability Determination Services office.
Section 1 - Claimant's Information and Number Holder's Information
Complete all of the information, including your Social Security Number. If you are filing your claim on someone else's Social
Security record, this person is the “number holder” and we need his or her information to process your claim.
Section 2 - Authorization for Disclosure
By selecting the disclosure box, you are authorizing us to give information to your representative's staff, partners, associates and
other individuals who work for or with your representative (such as contractors and copying services). We will check the
credentials of the individuals requesting information on behalf of your representative for authentication purposes.
Section 4 - Representative's Information
Both you and your representative must complete all of the information in this section. It is important to fill in all the boxes, including
the Representative Identification Number (Rep ID). Ask your representative for his or her Rep ID, if you do not know it. This box
should only be left blank if your representative does not have a Rep ID.
If you appoint or have appointed multiple representatives, you must name your principal representative who will be our main point
of contact. We will send copies of your notices to this individual and communicate directly with him or her.
Section 3 - Principal Representative
Your representative must complete this section to let us know his or her status as a professional. If your representative is seeking
a fee and is working for an employer, entity or firm, he or she must also complete the affiliation section and give us the Employer’s
Identification Number (EIN). We will provide both your representative and the employer, entity, or firm with a copy of the form IRS
1099-MISC showing the reported income. For more information on form 1099-MISC and employer registration, visit our website at
www.ssa.gov/representation
. Your representative should also certify the accuracy of all statements in this section.
Section 5 - Representative's Status, Affiliations, and Certifications
Sections 206 and 1631(d) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this
information is voluntary. However, failing to provide all or part of the information may prevent us from appointing a representative
to act on your behalf.
We will use the information to verify the appointment of your representative and his or her acceptance of the appointment. We
may also share your information for the following purposes, called routine uses:
• To a congressional office in response to an inquiry from that office made on behalf of, and at the request of, the subject
of the record or a third party acting on the subject’s behalf;
• To Federal, State, and local law enforcement agencies and private security contractors, as appropriate, information
necessary:
(a) to enable them to protect the safety of Social Security Administration (SSA) employees and customers, the
security of the SSA workplace, and the operation of SSA facilities; or
(b) to assist investigations or prosecutions with respect to activities that affect such safety and security or
activities that disrupt the operation of SSA facilities; and
• To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration
of its programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089, entitled Claims
Folders Systems, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784; 60-0320, entitled Electronic
Disability Claim File, as published in the FR on December 22, 2003, at 68 FR 71210; and 60-0325, entitled Appointed
Representative File, as published in the FR on October 8, 2009, at 74 FR 51940. Additional information and a full listing of all our
SORNs are available on our website at www.ssa.gov/privacy.
Form SSA-1696 (02-2020) UF
Page 2 of 6
Section 6 - Claim Type
Either you or your representative can complete this section. Check all types of claims for which you seek representation.
Section 7 - Fee Arrangement
Complete this section, if your representative is or will be asking for a fee for services performed on your claim. Generally, to
charge a fee for services, your representative must get our approval. Your representative may waive the right to charge you a fee
or tell us that a third party entity (business, government agency, or organization) will pay the fee. In these situations, the third party
must pay out of its own funds the fee and any expenses, and you and any auxiliary beneficiaries (e.g., children or spouse) must
be free of responsibility to pay any fees or expenses. If your representative is eligible for direct payment, he or she also may waive
the right to direct payment.
Section 8 - Signatures
You must sign and date this section. If your representative is not an attorney, he or she also must sign and date this section. We
also encourage attorneys to sign this section to confirm that they will abide by our rules.
Privacy Act Statement - Collection and Use of Personal Information
Paperwork Reduction Act Statement
This information collection meets the clearance requirements of 44 U.S.C. §3507, as amended by Section 2 of the Paperwork
Reduction Act of 1995. 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 take about 30 minutes to read the instructions, gather the facts, and answer the questions.
You may send us your comments on our estimated completion time to SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.
Send only comments relating to our time estimate to this address, not the completed form.
References
• 18 U.S.C. §§ 203, 205, and 207; 42 U.S.C. §§ 406, 1320a-6, 1383(d)(2) and 1631;
• 26 U.S.C. §§ 6041 and 6045(f) and 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq.
Mailing Address
Section 1 - Claimant's Information
First Name Initial Last Name
City State ZIP/Postal Code Country - if outside the U.S.
Phone Number Alternate Phone Number (Optional)
Country/Area Code Phone Number Phone NumberCountry/Area Code
Number Holder's Information (Complete when applicable)
My claim is based on another person’s work or earnings (e.g., spouse or parent). This person’s information is different from mine.
Section 2 - Disclosure (Claimant Only)
By selecting this box, I, the claimant listed in Section 1, whose signature appears in Section 8, authorize SSA to release
information in relation to my pending claim(s) or asserted right(s) to designated associates who perform administrative duties
(e.g., clerks, assistants), partners, or parties under contractual arrangements for or with my representative. (The appointed
representative’s partners, associates, delegates and designees must be prepared to provide information in order to be
authenticated.)
Section 3 - Principal Representative (Claimant only – Complete when applicable)
I have appointed before, or appoint now, more than one representative. I ask SSA to make contacts or send notices to this
individual. My principal representative is:
Name
Last NameInitialFirst Name
--
Number Holder's Social Security Number
Social Security Number
- -
Claimant's Appointment of a Representative
Page 3 of 6
OMB No. 0960-0527
Form SSA-1696 (02-2020) UF
Discontinue Prior Editions
Social Security Administration
Claimant's Social Security Number Appointed Representative's Rep ID
- -
123 Main Street
Tiffany
Anne
Baxter
Some City
YY
12345
777
888‐9999
Maria Rivera
9 9 9 9
9 9 9
9 9
9 9 9
9 9
9 9 9 9
City
Representative's Rep ID
Form SSA-1696 (02-2020) UF
Section 5 - Representative's Status, Affiliations, and Certifications (Representative Only)
Representative's Status Part A - Type of Representative (Representatives have a duty to keep their information current)
I am an attorney (SSA regulation states that an attorney is someone in good standing who has the right to practice law
before a court of a State, Territory, District, or island possession of the United States, or before the Supreme Court or a
lower Federal court of the United States.)
I am a non-attorney eligible for direct payment (SSA law requires that non-attorneys meet certain criteria to qualify for direct
payment. Refer to our website at www.ssa.gov/representation for criteria).
I am a non-attorney not eligible for direct payment.
Representative's Status Part B - Disqualification
I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice law.
NoYes
I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.
NoYes
Claimant's Social Security Number Appointed Representative's Rep ID
- -
First Name Initial Last Name
Mailing Address
State ZIP/Postal Code Country - if outside the U.S.
Phone Number Alternate Phone Number (Optional)
Country/Area Code Phone Number Phone NumberCountry/Area Code
Section 4 - Representative's Information (Claimant and Representative)
Representatives who are eligible and seek direct payment of their fee must register and receive a Rep ID before the appointment.
For more information about registration visit us on-line at www.socialsecurity.gov/ar, contact us at 1-800-772-1213
(TTY 1-800-325-0778), or visit your local Social Security office.
Page 4 of 6
Some Town
9 9 9
9 9
9 9 9 9
Maria
Rivera
5678 That Street
,
YY
12345
222
333-4444
Form SSA-1696 (02-2020) UF Page 5 of 6
I accept this appointment and certify the following:
• I understand and agree that I will comply with SSA's laws and rules on the representation of parties, including the Rules of
Conduct and Standards of Responsibility for Representatives; I will not charge, collect, or retain a fee for representational
services that SSA has not approved or that is more than SSA approved unless a regulatory exclusion applies.
• I understand that if I fail to comply with any of SSA's laws and rules I may be suspended or disqualified as a representative
before SSA.
• I will not disclose any information to any unauthorized party without the claimant's specific written consent.
• I am not currently suspended or prohibited, for any reason, from practicing before the Social Security Administration.
• I am not disqualified from representing the claimant as a current or former officer or employee of the United States.
• I accept appointment as the representative for the claimant named in Section 2 of this form in connection with the claims and
asserted rights described in Section 6 of this form.
• I agree that a copy of this signed form SSA-1696 will have the same force and effect as the original.
• I declare under penalty of perjury that I have examined all of the information on this form and on all accompanying statements or
forms, including any information, attestations and certifications provided to SSA in registration, and that they are all currently true
and correct to the best of my knowledge.
If I intend to seek direct payment of the authorized fee on this claim -
• I have registered for and obtained a Rep ID, and my registration information is up-to-date.
• I have provided up-to-date information on my registration concerning whether I have been suspended or prohibited from practice
before SSA or any other Federal program or agency, disbarred or suspended by a court or bar, and convicted of a violation
under Section 206 or 1631(d) of the Social Security Act.
I CERTIFY TO ALL OF THE ABOVE (Representative's Initials)
Representative's Certification
Claimant's Social Security Number Appointed Representative's Rep ID
- -
Affiliation Information
If you are representing the claimant(s) as a partner or employee of a business entity, firm or other organization you may provide
your Employer Identification Number (EIN) here, if one exists for tax purposes. This number is not your Social Security Number
(SSN). This is your employer’s tax identification number.
(Do not complete this section if you do not qualify for direct payment.)
Representative's Business Address (if different than mailing address)
Organization’s Name (Enter the full name of the business, entity, firm or organization with which you want to be affiliated while
representing this claim)
City State ZIP/Postal Code
Country - if outside the U.S.
Section 5 - Continued (Representative Only)
-
EIN
MR
9 9 9
9 9
9 9 9 9
XYZ Community Mental Health Center
Form SSA-1696 (02-2020) UF
Claimant's Social Security Number Appointed Representative's Rep ID
- -
Section 6 - Claim Type (Claimant or Representative)
I appoint the individual named in Section 4 to act as my representative in connection with my claim(s) or asserted right(s) under
Title II (RSDI), Title XVI (SSI), Title XVIII (Medicare Coverage), and Title VIII (SVB) of the Social Security Act, as presently
amended, specifically for the issues identified below: (Check all that apply)
Claim/Appeal for Retirement Benefits
Claim/Appeal for Title II Disability Benefits
Claim/Appeal for Title XVIII (Medicare), VIII (Special Veteran’s Benefits)
Continuing Disability Review (CDR)
Post-Entitlement Issue (a new issue you raise after eligibility for other benefits)
Section 7 - Fee Arrangement (Representative Only)
Check one box below:
I will request a fee and direct payment of this fee. Select this box if you are eligible for direct payment and want us to
withhold a portion of the past-due benefits to pay you the fee we may authorize. (We must authorize the fee.)
I will request a fee but not direct payment. Select this box if you are not eligible for direct payment from the past-due
benefits, or if you do not want direct payment. You must collect any fee we may authorize on your own. (We must
authorize the fee.)
I waive the right to receive a fee from the claimant, any auxiliary beneficiaries or any other individual. Select this
box if you certify that an entity, or a Federal, state, county, or city government agency will pay the fee and any expenses
from its funds. The claimant, auxiliary beneficiaries, or other individuals must not be liable for the fee, directly or indirectly,
in whole or in part, or any expenses. (We do not need to authorize the fee if all regulatory conditions apply.)
Section 8 - Signatures (Claimant and Representative)
Representative's Signature
Date
Date
Claimant's Signature
(E.g., benefit amount, month of entitlement, representative payee, suspension, termination, overpayment)
Page 6 of 6
Claim/Appeal for Title XVI Disability Benefits
Concurrent Title II and Title XVI Disability Benefits
I waive the right to a fee.
9 9 9
9 9
9 9 9 9
7/23/2020
7/23/2020
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Completed 30 November 2020

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