Form SSA-1696 (08-2020) 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
. Your representative should also certify the accuracy of all statements in this section.
Section 5 - Representative's Status, Affiliations, and Certifications