Fillable Ssa-1693 Fee Agreement for Representation before the Social Security Administration

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Ssa-1693 Fee Agreement for Representation before the Social Security Administration

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Form SSA-1693 (12-2018)
Social Security Administration
Page 1 of 5
OMB No. 0960-0810
INSTRUCTIONS FOR COMPLETING FORM SSA-1693
Keep a copy of this form for your records.
File Form SSA-1693 only if you are submitting or have submitted a notice of appointment (i.e., SSA-1696 or equivalent writing) on
an active claim or issue pending decision with us.
In this document, “you” means the claimant, beneficiary, auxiliary beneficiary or spouse.
Requesting a fee for representational services
Your representative may ask for a fee for the services he or she provided in your claim. Not all representatives ask for a fee, and
some only charge a fee if they win your case. To charge you a fee for services related to your claim(s), your representative
generally must obtain our approval. Your representative can do that by submitting a fee agreement (you may use this form) or a
fee petition. You and your representative choose which of these two processes to use. For more information on fees, fee
processes and our rules, visit our website at www.ssa.gov/representation.
Representatives who seek direct payment of their fee must first register with us. For more information on representative
registration visit us on-line at www.socialsecurity.gov/ar, contact us at 1-800-772-1213 (TTY 1-800-325-0778), or contact your
local Social Security office.
Registration
Your representative must file your fee agreement before we decide your case. If you or your representative submit the fee
agreement after our decision, we will disapprove your fee agreement.
When to file a fee agreement
Under the terms of a fee agreement, you will pay an amount up to 25 percent of your total past-due benefits or an amount set by
us, whichever is less. You must pay the fee we authorize. Your dependents or your auxiliary beneficiaries will also pay a fee
unless they have their own representation. You may also have to pay:
• Fees authorized by a Federal court for services your representative provided during the court proceedings, and
• Any “out-of-pocket” expenses your representative may incur (e.g., costs for making copies of a doctor's or hospital's records).
Note: These fees and expenses do not require our authorization.
What you have to pay
Although representatives may only use either a fee agreement or a fee petition in each case (they are mutually exclusive), you
and your representatives can limit the effect of a fee agreement to a certain appeal level. Representatives can file a fee petition if
your case is appealed beyond the specified administrative level. You and your representative can choose this option on the
attached form.
Two-tiered fee agreements
Your representative may accept money from you before we authorize a fee as long as he or she holds it in a trust or escrow
account according to our rules and policy. If you choose to enter into the trust or escrow agreement with your representative, you
may willingly deposit the money in the trust or escrow account.
Trust and escrow accounts
We collect information on payments your representative may receive from a third party for services he or she provided to you
during the administrative proceedings. These fees may be in lieu of your fee payment, or may be in addition to your payment. We
may consider these payments during our authorization process to determine if we need to authorize these fees under our rules.
All statutory and regulatory rules continue to apply in situations involving third-party payments.
Third-party payments
If your representative is eligible under our rules to receive an authorized fee directly from us, we usually withhold 25 percent of
your TII/TXVI past-due (retroactive) benefits for direct payment of that fee. However, you must pay your representative the
authorized fee directly if:
• the amount of the fee we approve is more than the amount held for you in a trust or escrow account, or more than the amount
we can pay to your representative from your past-due benefits,
• we did not withhold past-due benefits,
• your claim did not result in past-due benefits,
• your representative is not eligible under our rules for direct payment of the fee from us,
• you ended the appointment of the representative before we issued a favorable decision,
• your representative withdrew from representing you before we issued a favorable decision,
Withholding of funds and direct payment to your representative
Form SSA-1693 (12-2018) Page 2 of 5
• we withheld but later released your past-due benefits to you because your representative did not:
○ ask for our approval of a fee until 60 days after the date of your notice of award, or
○ timely tell us that he or she planned to ask for a fee
You and your representative must sign and date this form. If you are appointing multiple representatives, all of your
representatives who intend to seek a fee for services provided on your claim must sign on a single fee agreement for the fee
agreement to be approved. They may use the last page for this purpose.
Signatures
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 affect the amount of fees authorized for
services rendered before us.
We will use the information to authorize fees for services rendered to the claimant named on the form. We may also share the
information for the following purposes, called routine uses:
• To a claimant’s representative to the extent necessary to dispose of a fee petition or fee agreement; except for
pre-decisional deliberative documents, such as analyses and recommendations prepared for the decision-maker;
• To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration
in the efficient administration of its programs; and
• To the Internal Revenue Service and to State and local government tax agencies in response to inquiries regarding
receipt of fees we paid directly starting in calendar year 2007.
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) 60-0003, entitled Attorney Fee
File, as published in the Federal Register (FR) on January 11, 2006, at 71 FR 1803; 60-0089, entitled Claims Folders Systems, as
published in the FR on April 1, 2003, at 68 FR 15784; 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.
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 (OMB) control number. We estimate that it will take about 7 minutes to read the instructions, gather the facts, and
answer the questions. You may send us comments on our time estimate to: SSA, 6401 Security Boulevard, 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,
• 26 U.S.C. §§ 6041 and 6045(f)
• 42 U.S.C. §§ 406(a), 1320a-6, and 1383(d)2)
• 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq.
Representative's Phone Number
Form SSA-1693 (12-2018)
Social Security Administration
Page 3 of 5
OMB No. 0960-0810
Fee Agreement for Representation Before the Social Security Administration
General Information
You may use this form to file an agreement between you and your representative(s) to seek our authorization of the fee for
services your representative(s) will provide before us. Section 206 of the Social Security Act limits the fee we authorize under a
fee agreement to 25 percent of your past-due (retroactive) benefits or a maximum dollar amount we set, whichever is less. As of
2018, the maximum is $6000. Your dependents or auxiliary beneficiaries who do not have their own representation will also be
liable for a fee. This form does not limit you and your representative(s) from agreeing to any additional terms unrelated to the fee.
Requesting, receiving, or keeping a fee in excess of the legal limit or in excess of what we authorize is unlawful and may lead to
sanctions for your representative(s).
Representative's Information
Representative's Rep ID
First Name Initial Last Name
Representative's Mailing Address
City State ZIP/Postal Code
Country/Area Code Phone Number
Alternate Phone Number (Optional)
Phone NumberCountry/Area Code
First Name Initial Last Name
Claimant's Mailing Address
City State ZIP/Postal Code
Claimant's Phone Number Alternate Phone Number (Optional)
Country/Area Code Phone Number Phone NumberCountry/Area Code
Claimant's Social Security Number
- -
Claimant's Information
Form SSA-1693 (12-2018) Page 4 of 5
Claimant's Social Security Number Principal Appointed Representative's Rep ID
- -
Standard Fee Agreement
or
Choose One:
I agree to pay the maximum fee as stated in the preceding paragraph. ($6000 as of 2018).
I agree to pay less than the maximum
$ %.
If SSA favorably decides my claim(s) and the decision results in past-due (retroactive) benefits, I agree to pay my
representative(s) a fee that does not exceed the lesser of 25 percent of my past-due benefits or the maximum dollar amount
allowed under the Social Security Act Section 206(a)(2), or such higher amount set by the Commissioner of Social Security based
on the date Social Security Administration (SSA) authorizes my representative’s fee.
Read and acknowledge the following:
I understand that I, my eligible spouse, any affected auxiliary beneficiary, my representative or the decision maker
have the right to protest the fee authorized under this fee agreement, in writing, within 15 days from the authorization.
I understand that my representative may still request a fee even if my case does not result in past-due benefits, or the decision is
not favorable. If the fee agreement cannot be approved because there are no past-due benefits or for other reasons, my
representative may file a fee petition to request that SSA authorize a fee. I also understand that if there are no past-due benefits
withheld, if not enough past-due benefits are withheld, or if my representative is not eligible for direct payment by SSA, I will be
responsible to pay the authorized fee to my representative(s) directly. SSA does not authorize out-of-pocket costs and expenses
for which I am responsible to pay directly to my representative.
Claimant's Initials
Two-Tiered Fee Agreement
If SSA favorably decides my claim(s) above the administrative level, this fee agreement is void and my
representative(s) may seek a higher fee by filing a fee petition. SSA must authorize this fee.
Escrow/Trust Accounts or Third-party Payments
My representative will receive a fee from another party (e.g., state, county, private entity) for
With my consent my representative(s) has/have or will establish an escrow/trust account in the amount of
$
$
and I will have no financial responsibility to pay any fee, unless SSA authorizes the total fee.
Claimant and Representative Signatures
Only representatives who have been properly appointed can be authorized to receive a fee. The claimant and any appointed
representative not waiving a fee are each required to sign this fee agreement.
Claimant's Signature Date
DatePrincipal Representative's Signature
This page is optional - Use only if multiple appointed representatives want to sign the same fee agreement.
Representative's Rep ID
Form SSA-1693 (12-2018)
Additional Signatures
Page 5 of 5
Claimant's Social Security Number Principal Appointed Representative's Rep ID
- -
Additional Appointed Representative's Names and Signatures
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Completed 18 November 2019

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