Form SSA-1695 Identifying Information for Possible Direct Payment of A

Form Approved
OMB No. 0960-0730

Social Security Administration

Identifying Information for Possible Direct Payment of Authorized Fees
Information About the Claimant
First Name

Middle Name

Last Name

Suffix

Wage Earner's Name if different than above

Type of Benefits

Social Security Number

Wage Earner's Social Security Number if different

Title II (RSDI)

Title XVI (SSI)

Information about You, the Representative
Name

Social Security Number

City

P.O. Box, Street, Apt., or Suite No.
State

ZIP Code or Postal Zone

Phone Number (including area code)

Country

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

To SSA STAFF: After the information on this form is entered into the appropriate system(s),
immediately shred the form. Under no circumstances should this form be scanned, placed in a claims
file or otherwise retained.
Form SSA-1695 (09-2006)

Page 1

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, Request for Appointed
Representative's Direct Payment Information, 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.

Privacy Act Notice

See Revised Privacy Act Statement Attached

We are required by section 206(a) and 1631(d) of the Social Security Act to ask you to give us the information on this form. The
information is needed to facilitate direct payment of authorized fees and to meet the reporting requirements of the law. Although
responses to the questions are voluntary, failure to provide answers to the questions on this form will result in nonpayment for your
service.
The information obtained on this form is almost never used for any purpose other than that stated above. However, sometimes the law
requires us to disclose the facts on this form without your consent. For example, we must release this information to another person or
government agency if federal law requires that we do so or to contractors, as necessary, to assist SSA in the efficient administration of its
programs.
Explanations about the reasons why information you provide us may be used or given out are available in Social Security offices. If you
want to learn more about this, contact any Social Security office.

Paperwork Reduction Act Statement See Revised PRA Attached
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 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. You may send comments on our time
estimate above to SSA, 6401 Security Boulevard, Baltimore, MD, 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.
Form SSA-1695 (09-2006)

Page 2

SSA will insert the following revised Privacy Act and PRA Statements into the form at
its next scheduled reprinting:
Privacy Act Statement

Collection and Use of Personal Information

Sections 206(a) and 1631(d) of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide on this form to
facilitate direct payment of authorized fees and to meet the reporting requirements of the
law.
Completion of this form is voluntary; however, failure to provide all or part of the
information could result in nonpayment for your service.
We rarely use this information you supply for any purpose other than for determining
continuing eligibility. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not
limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights
to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department
of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity and improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local
government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for Federally-funded or administered benefit
programs and for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our
programs and systems is available on-line at www.socialsecurity.gov or at your local
Social Security office.

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 control number. We estimate that it will take about 10
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.