Fillable Form SSA-1696-U4 (03-2018) UF: Completing This Form to (SAMHSA)

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Form SSA-1696-U4 (03-2018) UF: Completing This Form to (SAMHSA)

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Completing This Form to Appoint a Representative
Page 1 of 9
OMB No. 0960-0527
Form SSA-1696-U4 (03-2018) UF
Discontinue Prior Editions
Social Security Administration
Choosing to be Represented How to Complete this Form
You can choose to have a representative help you when you
do business with Social Security. We will work with your
representative, just as we would with you. It is important that
you select a qualified person because, once appointed, your
representative may act for you in most Social Security matters.
We give more information, and examples of what a
representative may do, in the section titled “Information for
Claimants.”
Privacy Act Statement
Collection and Use of Personal Information
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:
1. 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.
2. 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
3. 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 (SORNs) 60-0089, entitled Claims
Folders Systems; 60-0320, entitled Electronic Disability Claim
File; and 60-0325, entitled Appointed Representative File.
Additional information and a full listing of all our SORNs are
available on our website at
www.socialsecurity.gov/foia/bluebook.
Please print or type your answers on this form. At the top of the
form, provide your full name and your Social Security number.
If your claim is based on another person's work and earnings,
also provide the “wage earner's” name and Social Security
number. If you appoint more than one individual as your
representative, you may want to complete a form for each of
them.
Part 1 Claimant's Appointment of Representative
Give the name and address of the individual(s) you are
appointing. You may appoint an attorney or any other qualified
individual to represent you. You also may appoint more than
one individual, but please refer to the “Information for
Claimants” section “What your Representative(s) May Charge”
for more information about payment of fees. You can appoint
one or more individuals in a firm, corporation, or other
organization as your representative(s), but you may not appoint
a law firm, legal aid group, corporation or organization itself.
Check the block(s) showing the program(s) under which you
have a claim. You may check more than one block. Check:
• Title II (RSDI), if your claim concerns retirement,
survivors, or disability insurance benefits.
• Title XVI (SSI), if your claim concerns Supplemental
Security Income.
• Title XVIII (Medicare Coverage), if your claim concerns
entitlement to Medicare or enrollment in the
Supplementary Medical Insurance (SMI) plan.
• Title VIII (SVB), if your claim concerns entitlement to
Special Veterans Benefits.
When you give your permission your representative may
designate an associate (e.g. a clerk), or other party or entity (e.
g. a copying service) to receive information from your claim file
on your representative's behalf for the duration of your claim. If
you want to give your representative permission to do that,
check the block to authorize this release.
If you will have more than one representative, check the
appropriate block and give the name of the individual you want
to be your principal representative. SSA will make contacts
with, and send notices or requests for development to, only the
principal representative. The principal representative will
provide copies of notices or requests to other co-
representatives.
You must sign and date the form. Print or type your address,
area code and telephone number.
If you are appointing a representative to replace a
representative that you discharged or who withdrew his or her
representation, you must notify us in writing that the prior
appointment has ended.
- This information
collection meets the 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 10 minutes to read the
instructions, gather the facts, and answer the questions. SEND
THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. The office is listed under U. S.
Government agencies in your telephone directory or you
may call Social Security at 1-800-772-1213 (TTY
1-800-325-0778). You may send comments on our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
Send only comments relating to our time estimate to this
address, not the completed form.
Each individual you appoint in Part I should also complete Part 2.
If the individual is not an attorney, he or she must give his or her
name, state that he or she accepts the appointment, and sign the
form.
Part 2 Representative's Acceptance of Appointment
Part 3 Fee Arrangement
To help in processing benefits and fee payments timely you and
your representative should complete this section. Your
representative should check a box, sign and date the form. Your
representative may choose to receive payment, waive direct
payment, or waive payment of the fee altogether. If you and your
representative change your arrangement before we decide your
claim, you can provide a new or amended form so that we can
update our records. If you appoint a second representative or co-
counsel who also will not charge a fee, he or she should also
complete this part or provide a new form, or if not using the form,
give us a separate, written waiver statement. If your
representative is not eligible for direct payment, or is an attorney
or an eligible non-attorney who waives direct payment, you will
be responsible for paying any fee we authorize.
Under certain circumstances, we do not have to authorize the
fee. These circumstances include where a Court has awarded a
fee based on your representative's actions as a legal guardian or
court-appointed representative, or where a business (such as an
insurance company), other organization or government agency
will pay your representative's fee and you and your beneficiaries
have no liability to pay any fees or expenses.
Paperwork Reduction Act Statement
References
• 18 U.S.C. §§ 203, 205, and 207; and 42 U.S. C. §§ 406 (a),
1320a-6, and 1383(d)(2)
• 20 CFR §§ 404.1700 et. seq., 408.1101, and 416.1500 et. seq.
• Social Security Rulings 83-27 and 82-39
• 26 U.S.C. §§ 6041 and 6045(f)
Form SSA-1696-U4 (03-2018) UF Page 2 of 9
Form SSA-1696-U4 (03-2018) UF Page 3 of 9
Information for Representatives
An attorney or other individual who wants to charge or collect a
fee for providing services in connection with a claim before the
Social Security Administration (SSA) must generally obtain our
prior authorization of the fee for representation. The only
exceptions are if:
• certain requirements are met and a third-party entity, such as a
business, an insurance carrier, a for profit, or nonprofit
organization or a government agency will pay the fee and any
expenses from its own funds and the claimant and auxiliary
beneficiaries incur no liability, directly or indirectly, for the cost
(s); or
• a Federal court awarded a fee based on the representative's
activities as the claimant's legal guardian or court-appointed
representative;
• a Federal court awarded a fee for representational services
provided before the court. In those cases, neither the Federal
court nor SSA can authorize a fee for the other.
Fees for Representation
Obtaining Authorization of a Fee
To charge a fee for services, you must use one of two mutually
exclusive fee authorization processes. You must file either a fee
petition or a fee agreement with us. In either case, you cannot
charge more than the fee amount we authorize.
Fee Petition Process
You may file a fee petition after you complete your services to
the claimant. This written request must describe in detail the
amount of time you spent on each service provided and the
amount of the fee you are requesting. In order to directly pay you
under a fee petition, you must either file a fee petition or notify us
within 60 days after we decide the claim of your intent to file a
fee petition.
You must give the claimant a copy of the fee petition and each
attachment. The claimant may disagree with the information
shown by contacting a Social Security office within 20 days of
receiving his or her copy of the fee petition. We will consider the
reasonable value of the services provided, and send you notice
of the amount of the fee you can charge.
Fee Agreement Process
If you and the claimant have a written fee agreement, one of
you must give it to us before we decide the claim(s). We
usually will approve the agreement if:
• you both signed it;
• the fee you agreed on is no more than 25 percent of past-due
benefits, or $6,000 (or a higher amount we set and announce
in the Federal Register), whichever is less;
• we approve the claim(s); and
• the claim results in past-due benefits.
We will send you a copy of the notice we send the claimant
telling him or her the amount of the fee you can charge based
on the agreement.
If we do not approve the fee agreement, we will tell you in
writing. We also will tell you and the claimant that you must file
a fee petition if you wish to charge and collect a fee.
After we tell you the amount of the fee you can charge, you or
the claimant may ask us in writing to review the authorized fee.
If we approved a fee agreement, the person who decided the
claim(s) also may ask us to lower the amount. Someone who
did not decide the amount of the fee the first time will review
and finally decide the amount of the fee.
Collecting a Fee
You may accept money for your fee in advance, as long as you
hold it in a trust or escrow account. The claimant never owes
you more than the fee we authorize, except for:
• any fee a Federal court allows for your services before it; and
• out-of-pocket expenses you incur or expect to incur, for
example, the cost of getting evidence. Our authorization is
not needed for such expenses.
If you are not an attorney and you are ineligible to receive
direct payment, you must collect the authorized fee from the
claimant. If you are interested in becoming eligible to receive
direct payment, you can find more information about this on our
"Representing Social Security Claimants" website:
http://www.ssa.gov/representation/
.
Form SSA-1696-U4 (03-2018) UF Page 4 of 9
If you are an attorney or a non-attorney whom SSA has found
eligible to receive direct payment and you register with SSA, as
described below, we usually withhold 25 percent of any past-due
benefits that result from a favorably decided retirement,
survivors, disability insurance, or supplemental security income
claim. Once we authorize a fee, we pay you all or part of the fee
from the funds withheld. We will also charge you the assessment
required by section 206(d) and 1631(d)(2)(C) of the Social
Security Act. You cannot charge or collect this expense from the
claimant. You will need to collect from the claimant:
• the rest of the fee he or she owes, if the amount of the
authorized fee is more than the amount of money we withheld
and paid you for the claimant, plus any amount you held for the
claimant in a trust or escrow account.
• all of the fee he or she owes, if we did not withhold past-due
benefits, (for example, because there are no past-due benefits;
you waived direct payment or did not register for direct
payment; the claimant discharged you or you withdrew from
representing before we issued a favorable decision); or we
withheld past-due benefits, but you did not ask us to authorize
a fee or tell us that you planned to ask for a fee within 60 days
after the date of the notice of award and we released the
withheld amount to the claimant.
Registering for Direct Fee Payment
If you are eligible and want to receive direct payment, you must
register with us before we effectuate a favorable decision on the
claim. To register, you must submit a Form SSA-1699
(Registration of Individuals and Staff for Appointed
Representative Services) once and a Form SSA-1695
(Identifying Information for Possible Direct Payment of
Authorized Fees) with each appointment. We will use the
information you provide on these forms to issue you a Form
1099-MISC if we pay you aggregate fees of $600 or more in a
calendar year. The Internal Revenue Code requires that we do
this. For information on the registration process, see our
"Representing Social Security Claimants" website
http://www.ssa.gov/representation/
.
Conflict of Interest and Penalties
If you commit improper acts, you can be suspended or
disqualified from representing anyone before SSA. You also
can face criminal prosecution. Improper acts include:
• If you are or were an officer or employee of the United States,
providing services as a representative in certain claims against
and other matters affecting the Federal government.
• Knowingly and willingly furnishing false information.
• Charging or collecting an unauthorized fee, or charging or
collecting too much for services provided in any claim,
including services before a court that made a
favorable decision.
References
• 18 U.S.C. §§ 203, 205, and 207; and 42 U.S.C. §§ 406 (a),
1320a-6, and 1383(d)(2)
• 20 CFR §§ 404.1700 et. seq., 408.1101, and 416.1500 et.
seq.
• Social Security Rulings 83-27 and 82-39
• 26 U.S.C. §§ 6041 and 6045(f)
, hereby accept the above appointment. I certify that I have not
been suspended or prohibited from practice before the Social Security Administration; that I am not disqualified from representing
the claimant as a current or former officer or employee of the United States; and that I will not charge or collect any fee for the
representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to
on the reverse side of the representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will
notify the Social Security Administration. (Completion of Part 3 satisfies this requirement.)
Part 1 - Claimant's Appointment of Representation
Form SSA-1696-U4 (03-2018) UF
Discontinue Prior Editions
Social Security Administration
Page 5 of 9
OMB No. 0960-0527
Please read the instructions before completing the form.
Name (Claimant) (Print or Type)
Wage Earner (If Different)
Social Security Number
Social Security Number
I appoint this individual,
to act as my representative in connection with my claim(s) or asserted right(s) under:
Title XVI (SSI)Title II (RSDI) Title XVIII (Medicare) Title VIII (SVB)
This individual may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get
information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I authorize the Social Security Administration to release information about my pending claim(s) or asserted right(s) to
designated associates who perform administrative duties (e.g. clerks), partners, and/or parties under contractual
arrangements (e.g. copying services) for or with my representative.
I appoint, or I now have, more than one representative. My principal representative is:
Name of Principal Representative
Address
Signature (Claimant)
Telephone Number (with Area Code)
Fax Number (with Area Code) Date
Part 2 - Representative's Acceptance of Appointment
I,
Check one:
I am an attorney I am a non-attorney eligible for direct payment under SSA law.
I am a non-attorney not eligible for direct payment.
I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice as
an attorney.
NoYes
I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.
NoYes
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge.
Date
Address
Signature (Representative)
Telephone Number (with Area Code) Fax Number (with Area Code)
Part 3 - Fee Arrangement
(Select an option, sign and date this section.)
I am charging a fee and requesting direct payment of the fee from withheld past-due benefits. (SSA must authorize the fee
unless a regulatory exception applies.)
I am charging a fee but waiving direct payment of the fee from withheld past-due benefits - I do not qualify for or do not
request direct payment. (SSA must authorize the fee unless a regulatory exception applies.)
I am waiving fees and expenses from the claimant and any auxiliary beneficiaries - By checking this block I certify that
my fee will be paid by a third-party entity or government agency, and that the claimant and any auxiliary beneficiaries are free
of all liability, directly or indirectly, in whole or in part, to pay any fee or expenses to me or anyone as a result of their claim(s)
or asserted right(s). (SSA does not need to authorize the fee if a third-party entity or a government agency will pay from its
funds the fee and any expenses for this appointment. Do not check this block if a third-party individual will pay the fee.)
I am waiving fees from any source - I am waiving my right to charge and collect any fee, under sections 206 and 1631 (d)(2)
of the Social Security Act. I release my client and any auxiliary beneficiaries from any obligations, contractual or otherwise,
which may be owed to me for services provided in connection with their claim(s) or asserted right(s).
Date
File Copy
Signature (Representative)
Annie M. Farnsworth
111-11-1111
Harriet Jones, Some Town Family Shelter, 123 Some Town St, SomeTown, YY 12345
Some Town Family Shelter,123Some Town St,Some
Town, YY 12345
(333)333-3333
10/31/18
Harriett Jones (SOAR Case Worker)
10/31/18
Some Town Family Shelter,123Some Town St,Some
Town, YY 12345
(444)444-4444
, hereby accept the above appointment. I certify that I have not
been suspended or prohibited from practice before the Social Security Administration; that I am not disqualified from representing
the claimant as a current or former officer or employee of the United States; and that I will not charge or collect any fee for the
representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to
on the reverse side of the representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will
notify the Social Security Administration. (Completion of Part 3 satisfies this requirement.)
Part 1 - Claimant's Appointment of Representation
Form SSA-1696-U4 (03-2018) UF
Discontinue Prior Editions
Social Security Administration
Page 6 of 9
OMB No. 0960-0527
Please read the instructions before completing the form.
Name (Claimant) (Print or Type)
Wage Earner (If Different)
Social Security Number
Social Security Number
I appoint this individual,
to act as my representative in connection with my claim(s) or asserted right(s) under:
Title XVI (SSI)Title II (RSDI) Title XVIII (Medicare) Title VIII (SVB)
This individual may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get
information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I authorize the Social Security Administration to release information about my pending claim(s) or asserted right(s) to
designated associates who perform administrative duties (e.g. clerks), partners, and/or parties under contractual
arrangements (e.g. copying services) for or with my representative.
I appoint, or I now have, more than one representative. My principal representative is:
Name of Principal Representative
Address
Signature (Claimant)
Telephone Number (with Area Code)
Fax Number (with Area Code) Date
Part 2 - Representative's Acceptance of Appointment
I,
Check one:
I am an attorney I am a non-attorney eligible for direct payment under SSA law.
I am a non-attorney not eligible for direct payment.
I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice as
an attorney.
NoYes
I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.
NoYes
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge.
Date
Address
Signature (Representative)
Telephone Number (with Area Code) Fax Number (with Area Code)
Part 3 - Fee Arrangement
(Select an option, sign and date this section.)
I am charging a fee and requesting direct payment of the fee from withheld past-due benefits. (SSA must authorize the fee
unless a regulatory exception applies.)
I am charging a fee but waiving direct payment of the fee from withheld past-due benefits - I do not qualify for or do not
request direct payment. (SSA must authorize the fee unless a regulatory exception applies.)
I am waiving fees and expenses from the claimant and any auxiliary beneficiaries - By checking this block I certify that
my fee will be paid by a third-party entity or government agency, and that the claimant and any auxiliary beneficiaries are free
of all liability, directly or indirectly, in whole or in part, to pay any fee or expenses to me or anyone as a result of their claim(s)
or asserted right(s). (SSA does not need to authorize the fee if a third-party entity or a government agency will pay from its
funds the fee and any expenses for this appointment. Do not check this block if a third-party individual will pay the fee.)
I am waiving fees from any source - I am waiving my right to charge and collect any fee, under sections 206 and 1631 (d)
(2) of the Social Security Act. I release my client and any auxiliary beneficiaries from any obligations, contractual or
otherwise, which may be owed to me for services provided in connection with their claim(s) or asserted right(s).
Date
Claimant Copy
Signature (Representative)
Annie M. Farnsworth
111-11-1111
Harriet Jones, Some Town Family Shelter, 123 Some Town St, SomeTown, YY 12345
Some Town Family Shelter,123Some Town St,Some
Town, YY 12345
(333)333-3333
10/31/18
Harriett Jones (SOAR Case Worker)
10/31/18
Some Town Family Shelter,123Some Town St,Some
Town, YY 12345
(444)444-4444
Form SSA-1696-U4 (03-2018) UF
Page 7 of 9
What Your Representative(s) May Do
Information for Claimants
What Your Representative(s) May Charge
Each representative you appoint can ask for a fee. To charge
you a fee for services, your representative must get our
authorization if you or another individual will pay the fee.
However, as described in “Completing this form to appoint a
representative, Part 3 Fee Arrangement” section of this form,
under certain circumstances, we do not have to authorize the
representative's fee. To request a fee, your representative must
file a fee agreement or a fee petition. In either case, your
representative cannot charge you more than the fee amount we
authorize. If he or she does, promptly report this to your Social
Security office.
Filing A Fee Petition
Your representative may file a fee petition when his or her work
on your claim(s) is complete. This written request describes in
detail the amount of time your representative spent on each
service he or she provided you. The request also gives the
amount of the fee the representative wants to charge for these
services. Your representative must give you a copy of the fee
petition and each attachment. If you disagree with the
information shown in the fee petition, contact your Social
Security office. Please do this within 20 days of receiving your
copy of the petition.
We will review the petition and consider the reasonable value of
the services provided. Then we will tell you in writing the amount
of the fee we authorize.
We will work directly with your appointed representative unless
he or she asks us to work directly with you. Your representative
may:
• get information from your claim(s) file;
• with your permission, designate associates who perform
administrative duties (e.g. clerks), partners and/or parties under
contractual arrangements (e.g., copying services) to receive
information from us on his or her behalf (by checking the
appropriate block and signing this form, you are providing your
permission for your representative to designate such
associates, partners, and/or contractual parties);
• give us evidence or information to support your claim;
• come with you, or for you, to any interview, conference, or
hearing you have with us;
• request a reconsideration, a hearing, or Appeals Council
review; and
• help you and your witnesses prepare for a hearing and
question any witnesses.
Also, your representative will receive a copy of the decision(s)
we make on your claim(s). We will rely on your representative to
tell you about the status of your claim(s), but you still may call or
visit us for information.
You and your representative(s) are responsible for giving Social
Security accurate information. It is wrong to knowingly and
willingly furnish false information. Doing so may result in criminal
prosecution.
We usually continue to work with your representative until (1)
you notify us in writing that he or she no longer represents you;
or (2) your representative tells us that he or she is withdrawing or
indicates that his or her services have ended (for example, by
filing a fee petition or not pursuing an appeal). We do not
continue to work with someone who is suspended or disqualified
from representing claimants. We will inform you if we suspend
your representative.
Filing A Fee Agreement
If you and your representative have a written fee agreement,
one of you must give it to us before we decide your claim(s).
We usually will approve the agreement if:
• you both signed it;
• the fee you agreed on is no more than 25 percent of past-due
benefits, or $6,000 (or a higher amount we set and announced
in the Federal Register), whichever is less;
• we approve your claim(s); and
• your claim results in past-due benefits.
We will tell you in writing the amount of the fee your
representative can charge based on the agreement.
If we do not approve the fee agreement, we will tell you and
your representative in writing. If your representative wishes to
charge and collect a fee, he or she must file a fee petition.
After we tell you the amount of the fee your representative can
charge, you or your representative can ask us to look at it
again if either or both of you disagree with the amount. If we
approved a fee agreement, the person who decided your claim
(s) also may ask us to lower the amount. Someone who did not
decide the amount of the fee the first time will review and finally
decide the amount of the fee.
How Much You Pay
You never owe more than the fee we authorize, except for:
• any fee a Federal court allows for your representative's
services before it; and
• out-of-pocket expenses your representative incurs or expects
to incur, for example, the cost of getting your doctor's or
hospital's records. Our authorization is not needed for such
expenses.
Your representative may accept money in advance as long as
he or she holds it in a trust or escrow account. We usually
withhold 25 percent of your past-due benefits to pay toward the
fee for you if:
• your retirement, survivors, disability insurance, and/or
supplemental security income claim(s) results in past- due
benefits;
• your representative is an attorney or a non-attorney whom we
have determined to be eligible to receive direct payment of
fees; and
• your representative registers with us for direct payment
before we effectuate a favorable decision on your claim.
You must pay your representative directly:
• the rest of the fee you owe, if the amount of the authorized
fee is more than the money we withheld and paid to your
representative for you plus any amount your representative
held for you in a trust or escrow account.
• all of the fee you owe, if we did not withhold past-due
benefits, (for example, because there are no past-due
benefits; your representative waived direct payment, did not
register for direct payment, you discharged the
representative, or he or she withdrew from representing you,
before we issued a favorable decision); or we withheld an
amount from your past-due benefits, but your representative
did not ask us to authorize a fee or tell us that he or she
planned to ask for a fee within 60 days after the date of your
notice of award and we released the withheld amount to you.
Representative Copy
, hereby accept the above appointment. I certify that I have not
been suspended or prohibited from practice before the Social Security Administration; that I am not disqualified from representing
the claimant as a current or former officer or employee of the United States; and that I will not charge or collect any fee for the
representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to
on the reverse side of the representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will
notify the Social Security Administration. (Completion of Part 3 satisfies this requirement.)
Part 1 - Claimant's Appointment of Representation
Form SSA-1696-U4 (03-2018) UF
Discontinue Prior Editions
Social Security Administration
Page 8 of 9
OMB No. 0960-0527
Please read the instructions before completing the form.
Name (Claimant) (Print or Type)
Wage Earner (If Different)
Social Security Number
Social Security Number
I appoint this individual,
to act as my representative in connection with my claim(s) or asserted right(s) under:
Title XVI (SSI)Title II (RSDI) Title XVIII (Medicare) Title VIII (SVB)
This individual may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get
information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I authorize the Social Security Administration to release information about my pending claim(s) or asserted right(s) to
designated associates who perform administrative duties (e.g. clerks), partners, and/or parties under contractual
arrangements (e.g. copying services) for or with my representative.
I appoint, or I now have, more than one representative. My principal representative is:
Name of Principal Representative
Address
Signature (Claimant)
Telephone Number (with Area Code)
Fax Number (with Area Code) Date
Part 2 - Representative's Acceptance of Appointment
I,
Check one:
I am an attorney I am a non-attorney eligible for direct payment under SSA law.
I am a non-attorney not eligible for direct payment.
I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice as
an attorney.
NoYes
I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.
NoYes
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge.
Date
Address
Signature (Representative)
Telephone Number (with Area Code) Fax Number (with Area Code)
Part 3 - Fee Arrangement
(Select an option, sign and date this section.)
I am charging a fee and requesting direct payment of the fee from withheld past-due benefits. (SSA must authorize the fee
unless a regulatory exception applies.)
I am charging a fee but waiving direct payment of the fee from withheld past-due benefits - I do not qualify for or do not
request direct payment. (SSA must authorize the fee unless a regulatory exception applies.)
I am waiving fees and expenses from the claimant and any auxiliary beneficiaries - By checking this block I certify that
my fee will be paid by a third-party entity or government agency, and that the claimant and any auxiliary beneficiaries are free
of all liability, directly or indirectly, in whole or in part, to pay any fee or expenses to me or anyone as a result of their claim(s)
or asserted right(s). (SSA does not need to authorize the fee if a third-party entity or a government agency will pay from its
funds the fee and any expenses for this appointment. Do not check this block if a third-party individual will pay the fee.)
I am waiving fees from any source - I am waiving my right to charge and collect any fee, under sections 206 and 1631 (d)
(2) of the Social Security Act. I release my client and any auxiliary beneficiaries from any obligations, contractual or otherwise,
which may be owed to me for services provided in connection with their claim(s) or asserted right(s).
Date
Signature (Representative)
Annie M. Farnsworth
111-11-1111
Harriet Jones, Some Town Family Shelter, 123 Some Town St, SomeTown, YY 12345
Some Town Family Shelter,123Some Town St,Some
Town, YY 12345
(333)333-3333
10/31/18
Harriett Jones (SOAR Case Worker)
10/31/18
Some Town Family Shelter,123Some Town St,Some
Town, YY 12345
(444)444-4444
OHO Copy
, hereby accept the above appointment. I certify that I have not
been suspended or prohibited from practice before the Social Security Administration; that I am not disqualified from representing
the claimant as a current or former officer or employee of the United States; and that I will not charge or collect any fee for the
representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to
on the reverse side of the representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will
notify the Social Security Administration. (Completion of Part 3 satisfies this requirement.)
Part 1 - Claimant's Appointment of Representation
Form SSA-1696-U4 (03-2018) UF
Discontinue Prior Editions
Social Security Administration
Page 9 of 9
OMB No. 0960-0527
Please read the instructions before completing the form.
Name (Claimant) (Print or Type)
Wage Earner (If Different)
Social Security Number
Social Security Number
I appoint this individual,
to act as my representative in connection with my claim(s) or asserted right(s) under:
Title XVI (SSI)Title II (RSDI) Title XVIII (Medicare) Title VIII (SVB)
This individual may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get
information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I authorize the Social Security Administration to release information about my pending claim(s) or asserted right(s) to
designated associates who perform administrative duties (e.g. clerks), partners, and/or parties under contractual
arrangements (e.g. copying services) for or with my representative.
I appoint, or I now have, more than one representative. My principal representative is:
Name of Principal Representative
Address
Signature (Claimant)
Telephone Number (with Area Code)
Fax Number (with Area Code) Date
Part 2 - Representative's Acceptance of Appointment
I,
Check one:
I am an attorney I am a non-attorney eligible for direct payment under SSA law.
I am a non-attorney not eligible for direct payment.
I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice as
an attorney.
NoYes
I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.
NoYes
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge.
Date
Address
Signature (Representative)
Telephone Number (with Area Code) Fax Number (with Area Code)
Part 3 - Fee Arrangement
(Select an option, sign and date this section.)
I am charging a fee and requesting direct payment of the fee from withheld past-due benefits. (SSA must authorize the fee
unless a regulatory exception applies.)
I am charging a fee but waiving direct payment of the fee from withheld past-due benefits - I do not qualify for or do not
request direct payment. (SSA must authorize the fee unless a regulatory exception applies.)
I am waiving fees and expenses from the claimant and any auxiliary beneficiaries - By checking this block I certify that
my fee will be paid by a third-party entity or government agency, and that the claimant and any auxiliary beneficiaries are free
of all liability, directly or indirectly, in whole or in part, to pay any fee or expenses to me or anyone as a result of their claim(s)
or asserted right(s). (SSA does not need to authorize the fee if a third-party entity or a government agency will pay from its
funds the fee and any expenses for this appointment. Do not check this block if a third-party individual will pay the fee.)
I am waiving fees from any source - I am waiving my right to charge and collect any fee, under sections 206 and 1631 (d)
(2) of the Social Security Act. I release my client and any auxiliary beneficiaries from any obligations, contractual or otherwise,
which may be owed to me for services provided in connection with their claim(s) or asserted right(s).
Date
Signature (Representative)
Annie M. Farnsworth
111-11-1111
Harriet Jones, Some Town Family Shelter, 123 Some Town St, SomeTown, YY 12345
Some Town Family Shelter,123Some Town St,Some
Town, YY 12345
(333)333-3333
10/31/18
Harriett Jones (SOAR Case Worker)
10/31/18
Some Town Family Shelter,123Some Town St,Some
Town, YY 12345
(444)444-4444
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Completed 20 December 2021

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