Fillable Ssa-1695 Identifying Information for ?Possible Direct Payment of Authorized Fees

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Ssa-1695 Identifying Information for ?Possible Direct Payment of Authorized Fees

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Form SSA-1695-F3 (02-2019)
Discontinue Prior Editions
Social Security Administration
Page 1 of 3
OMB No. 0960-0730
Identifying Information for
Possible Direct Payment of Authorized Fees
Information About the Claimant
First Name Middle Name
Last Name Suffix
Social Security Number
Wage Earner's Name (if different than above)
Wage Earner's Social Security
Number (if different)
Type of Benefits
Title II (RSDI) Title XVI (SSI)
Information About You, the Representative
Name
Social Security Number
P.O. Box, Street, Apt., or Suite No. City
State ZIP Code or Postal Zone Country
Phone Number (including area code) Fax Number (optional)
Employer Identification Number (EIN), if applicable. If you are representing the claimant(s) as a partner or an employee of a firm
or other business entity, you may provide the EIN of the firm or business. See instructions on Page 2 for more information.
Information About Other Claimants You are Representing in connection with this Claim
List below the Social Security Numbers and names of all other claimants not mentioned above. If all claimants will not fit on this
form, list on a separate form or blank paper.
Claimant's Social Security Number Claimant's Name
Form SSA-1695-F3 (02-2019) Page 2 of 3
Important Information
Purpose of Form
An attorney or other person who wishes to charge or collect a fee for providing services in connection with a claim before the
Social Security Administration (SSA) must first obtain approval from SSA. The request for appointment is generally made using
the SSA-1696-U4, Appointment of Representative, or equivalent written statement. An attorney or other person who wishes to
receive direct payment of authorized fees from SSA must have completed an SSA-1699, Registration for Appointed
Representative Services and Direct Payment, in order to provide the identifying information that will be used to process these
direct payments, including the possible use of direct deposit to a financial institution, and to meet any requirements for issuance
of a Form 1099-MISC. It is important to complete a new SSA-1699 whenever there are changes to identifying information. In
addition, an attorney or other person must complete this SSA-1695, Identifying Information for Possible Direct Payment of
Authorized Fees, for each claim in which a request is being made to receive direct payment of authorized fees.
Instructions for Completing the Form
Claimant Information - Please provide the Social Security Number (SSN) and name of the claimant that you will represent
before SSA.
Wage Earner Information - If the claim is being filed on the Social Security record of someone other than the claimant, please
provide the SSN and name of that wage earner.
Type of Benefits Information - Please specify the type of benefits for which you are representing the claimant(s).
Representative Information - Please enter your SSN and name as shown on your Social Security card and your mailing
address. If you have changed your last name (e.g., due to marriage), please contact your local SSA office to make this change to
your Social Security record. In addition, if you are representing the claimant(s) as a partner or employee of a firm or other
business entity, you may provide the EIN of that entity. This will allow SSA to issue a Form 1099-MISC to that entity to reflect that
the direct payment of authorized fees you receive is actually income to that entity for tax purposes.
Information About Other Claimants - If you are representing other claimants in this claim that are not mentioned above, please
provide their SSNs and names. If there are more than five individuals, please provide this information on a separate attachment
to this form.
Form SSA-1695-F3 (02-2019) Page 3 of 3
Privacy Act Statement
Collection and Use of Personal Information
Sections 206(a) 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 could result in nonpayment for your service.
We will use the information to facilitate direct payment of authorized fees and meet any requirement to issue a Form 1099-
MISC, pursuant to 26 United States Code (USC) 6041 and 26 USC 6045(f), under the Internal Revenue Service (IRS). We
may also share your information for the following purposes, called routine uses:
• To the Department of the Treasury, IRS, as necessary, for the purpose of auditing the Social Security
Administration's compliance with safeguard provisions of the Internal Revenue Code of 1986, as amended; and
• To a third party, as necessary, information relating to the qualifications and suitability of representative payees or
representative payee applicants to serve as representative payees, or their use of the benefits paid to them under
section 205(j) or section 1631(a) of the Social Security Act.
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 and 60-0222, entitled Master
Representative Payee File as published in the FR on April 22, 2013, at 78 FR 23811. 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 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 10 minutes to read the instructions, gather the facts, and
answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.
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Ssa-1695 Identifying Information for Possible Direct Payment of Authorized Fees

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Completed 18 November 2019

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