Current SSA-1691

SSA-1691 - Current Version.pdf

Non-Attorney Representative Demonstration Project Application

Current SSA-1691

OMB: 0960-0699

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Social Security Administration
Non-Attorney Representative Demonstration Project

OMB No. 0960-0699

You must complete this application carefully and provide all supporting documentation. You must provide all required
information before the end of the application period to be eligible for the Demonstration Project. If you have any
questions, please call CPS Human Resource Services toll free at 1-800-376-5728 or see the “What's New?” page of their
website at http://www.cps.ca.gov/tlc/ssa/new.asp for tips to make the application process easier.

Purpose of this Form
Section 303 of the Social Security Protection Act of
2004 (SSPA) Public Law no.108-203 provides for a
5-year demonstration project to be conducted by
SSA under which the direct payment of SSAapproved fees is extended to certain non-attorney
claimant representatives. Under the SSPA, to be
eligible for direct payment of fees, a non-attorney
representative must fulfill the following statutory
requirements: (1) Possess a bachelors degree or
have equivalent qualifications derived from training
and work experience; (2) pass an examination that
tests knowledge of the relevant provisions of the
Social Security Act; (3) secure professional liability
insurance or equivalent insurance; (4) pass a
background check; and (5) demonstrate completion
of relevant continuing education courses.
Section 303(b) of the SSPA permits the
Commissioner of Social Security to establish
additional prerequisites. Pursuant to that authority,
the Commissioner will require applicants to satisfy
a representational experience requirement to
participate in the demonstration project.

Applicants will pay their fees to CPS Human
Resource Services; and
Applicants who are not found to be eligible may
reapply during the next application phase, but they
will pay the full fee upon reapplying.
Education and Equivalent Qualifications
A bachelor's degree from an accredited institution
of higher education has been established as a
prerequisite for participating in the demonstration
project. However, applicants who do not have a
bachelor's degree may satisfy this prerequisite
based on combinations of training and work
experience that the Commissioner determines to be
equivalent to a bachelor's degree. We have
determined that any of the following combinations
of education and experience shall be equivalent to
having a bachelor's degree:
•

Through the services of a private contractor, CPS
Human Resource Services, SSA must collect the
requested information to determine if a nonattorney representative has met the requirements
to be eligible for direct payment of fees for his or
her claimant representation services. The
information collection is needed to comply with the
legislation. The respondents are non-attorney
representatives who apply for direct payment of
fees.

If the applicant does not have a bachelor's
degree, but has three years or more of
undergraduate study at an accredited
institution of higher learning, the applicant
must have at least one year of relevant
professional experience (as defined below),
at least six months of which must have
involved claims for benefits under title II or
title XVI of the Act;

•

Application Fee
SSPA section 303(c) (1) provides that the
Commissioner may assess applicants a reasonable
fee to cover the costs of administering the
prerequisites process. The fee will be $1000 (in
U.S. dollars) per applicant;

If the applicant has at least two, but less
than three years of undergraduate study at
an accredited institution of higher learning,
the applicant must have at least two years
of relevant professional experience, at least
one year of which must have involved
claims for benefits under title II or title XVI of
the Act;

•

If the applicant has at least one, but less
than two years of undergraduate study at an
accredited institution of higher learning, the
applicant must have at least three years of
relevant professional experience, at least
two years of which must have involved
claims for benefits under title II or XVI of the
Act; or

•

If the applicant has less than one year of
undergraduate study at an accredited
institution of higher learning, or no

Applicants must include the fee payment with their
application package;
Acceptable forms of fee payment will be by certified
check, money order, a check drawn from a private
firm's account, or credit card;
Page 1

undergraduate education, the applicant
must have received a high school diploma
or GED certificate and have at least four
years of relevant professional experience, at
least two years of which must have involved
claims for benefits under title II or title XVI of
the Act.
Relevant professional experience (for purposes of
establishing qualifications equivalent to a
bachelor's degree) is work through which the
applicant has demonstrated familiarity with medical
reports and an ability to describe and assess
mental and/or physical limitations. Such experience
may be from the fields of: Teaching, counseling or
guidance, social work, personnel management,
public employment service, and/or nursing or other
health care professional services. Any professional
work involving claims for benefits under title II or
title XVI of the Act shall also be defined as relevant
professional experience.
An applicant who fails to submit proof of a
bachelor's degree or equivalent qualifications
before the application period closes shall be
precluded from establishing, based on his or her
current application, eligibility to take the
examination and to participate in the demonstration
project. However, the applicant may re-apply to
participate in the demonstration project during a
subsequent application period. Proof of Education
is an official transcript showing the stamp or raised
seal, or otherwise establishing that it is an official
copy.
An applicant may possess a law degree (e.g., juris
doctor); however, attorneys who already qualify to
have their approved representatives' fees paid
directly from their clients' past-due benefits
pursuant to sections 206 and 1631(d)(2) of the Act
will be ineligible to participate in this demonstration
project. In addition, attorneys who are suspended
or disbarred by a State or Federal court or
disqualified from appearing before a Federal
agency or program will be ineligible to participate in
this demonstration project.
Representational Experience
All participants in the demonstration project (with or
without a bachelor's degree) must have
demonstrated experience in representing claimants
before SSA. Applicants must meet the following
minimum representational experience requirement:
The applicant must have provided representational
services as the appointed representative for five
claimants within a 24-month period;
Page 2

Representing a claimant before SSA can count
toward satisfaction of the representational
requirement only if the applicant was serving as the
claimant’s appointed representative at the time at
which SSA decided the case at any administrative
level (i.e. the initial, reconsideration, ALJ hearing,
or Appeals Council level) or, if the case has not
been decided while the applicant was the appointed
representative, the applicant appeared as the
claimant’s appointed representative at a hearing
before an ALJ;
The 24-month period must occur within the 60
months preceding the month in which the
application was filed.
The following is an example of how to calculate the
24- and 60- month periods for establishing
representational experience:
The applicant files his or her application in June
2005.
The 60-month period begins on July 18, 2000, and
ends on July 17, 2005 (the last day of the month
before the filing of the application).
The 24-month period can occur at any time
between July 18, 2000, and July 17, 2005. For
example, the applicant would meet the requirement
if he or she served as the appointed representative
for five separate claimants during the period from
January 2001 through December 2002.
Applicants are required to submit with their
applications the names and the complete Social
Security numbers of five claimants for whom the
applicant provided representational services during
the appropriate 24-month period. An applicant will
not be required to provide additional information
regarding the services provided a named claimant if
the applicant provides a copy of any one of the
following that the applicant received as the
appointed representative of that claimant during the
relevant 24-month period: a notice of either an
initial determination, a reconsideration
determination, an ALJ hearing, an ALJ decision, or
an Appeals Council decision. If the applicant is
unable to provide a copy of one of the specified
notices with respect to a named claimant, the
applicant will be asked to provide additional
information regarding the dates and administrative
level of the representational services provided that
claimant. You may not list a claimant unless:
a. You were the appointed representative of
the claimant at the time at which SSA

decides the case at any hearing level (initial,
reconsideration, ALJ hearing, Appeals
Council);
b. In cases that have not been finally decided,
you appeared as the claimant’s
representative at a hearing before an ALJ.
Types of Insurance
Non-attorney participants are required to have
professional liability insurance, or equivalent
insurance, which the Commissioner has
determined to be adequate to protect claimants in
the event of malpractice by the non-attorney
representative. This insurance policy must be
underwritten by a firm that is licensed to provide
insurance in the State in which the non-attorney
representative conducts business. The policy must
also provide coverage for professional liability
insurance claims made in those States in which the
non-attorney representative represents claimants
before SSA.
An individual must carry professional liability
insurance coverage of at least $100,000 per
incident and an annual aggregate coverage of
$500,000. Under a business policy, the minimum
per incident coverage is $100,000 and the
minimum annual aggregate coverage required is
determined in accordance with the following
schedule:

For 1-10 employees covered, a minimum
aggregate amount of $500,000
For 11-25 employees covered, a minimum
aggregate amount of $1 million
For 25-50 employees covered, a minimum
aggregate amount of $2 million
For 51-100 employees covered, a minimum
aggregate amount of $3 million
For 101-200 employees covered, a
minimum aggregate amount of $4 million
201 or more, a minimum aggregate amount
of $5 million.

An applicant who fails to submit proof of the
required insurance before the application period
closes shall be precluded from establishing, based
on his or her current application, eligibility to take
the examination and to participate in the
demonstration project. However, the applicant may
re-apply to participate in the demonstration project
during a subsequent application period.
Non-attorney representatives who establish
eligibility to participate in the demonstration project
will be required to maintain their insurance
Page 3

coverage in order to continue to receive direct fee
payments from SSA.
REMEMBER, your liability insurance must be
current for you to be eligible to participate in
the demonstration project. For example, if you
take the exam on June 7, 2006 and your insurance
lapses on July 1, 2006. You are notified on July 17,
2006 that you achieved a passing score. You will
not be eligible to participate in the demonstration
project, regardless of your test score, until you
notify us that you have again obtained the
necessary liability insurance and we verify that your
coverage meets minimum demonstration project
requirements.
Background Check
A background check is required of each nonattorney representative who applies to participate in
the demonstration project to ensure his or her
fitness to practice before SSA. SSA will reject any
applicant who:
•
•

•
•

Has been suspended or disqualified from
practice before SSA;
Has had a judgment or lien assessed
against him/her by a civil court for
malpractice and/or fraud;
Has had a felony conviction;
Engages in substantial misrepresentation in
submitting his or her application and/or
supporting materials for the application;
Fails to pass an SSA administrative records
check (check of SSN, etc.); or
Fails to provide documentation as
requested by CPS Human Resource
Services to perform the criminal background
investigation.

Examination
Applicants are required to pass an examination
testing their knowledge of the relevant provisions of
the Act and the most recent developments in
Agency and court decisions affecting titles II and
XVI of the Act. The examination is a 40 to 50
question, multiple choice examination. Examination
details are as follows:
•
•

•

The examination instrument will be written
in the English language only;
CPS Human Resource Services will be
administering the examination which will be
given only once, on a weekday, in
association with each application period;
During the examination, test-takers will have
open-book access to certain reference

materials that we will supply (see below for
details);
The examination will be based upon
situations that arise from the subject areas
contained in the reference materials; and
Applicants will not be permitted to remove
the examination instrument or reference
materials from the examination center.

•

Open-book reference materials: CPS will provide
one copy of the 20 C.F.R., Chapter III (Parts 400499) to each person taking the examination. In
addition, though not required for the examination,
CPS will provide two copies of the Compilation of
Social Security Laws, Volume 1 at each test
location. We may provide additional materials; if so,
we will provide details about the materials on the
CPS Human Resource Services website.
Applicants will not be permitted to bring any other
items (including reference materials) to the
examination center.
An applicant who fails to achieve a passing score
may re-apply to participate in the demonstration
project during a subsequent application period;
however, they will be required to pay the
application fee again.
Instructions for Completing this Form
1. Before you fill out the application, you should
have the following available:
•
•
•
•

•

College transcripts, to include complete
address
Your employment history for the past five
(5) years
Information on College Degree's
Names and SSN's for Claimants you have
represented and documents verifying your
representational experience, if available.
Your professional or business liability
insurance policy

2. Please type or print legibly using only a BLUE or
BLACK ink pen.
3. All sections of this form must be filled out
completely. If no response is necessary or
applicable, indicate this on the form (e.g. "None" or
"N/A").
4. All telephone numbers must include area codes.
5. All addresses must include Zip Codes.
6. Please list full middle name unless asked
Page 4

specifically for middle initial. If you do not have a
middle name, please indicate this by supplementing
"NMN" for a middle name.
7. All dates provided on this form must be in
Month/Day/Year or Month/Year format. Use
numbers (01-12) to indicate months. For example,
April 3, 1979, should be written as 04/03/1979. If
you cannot report the exact date, please indicate
with "EST."
8. The preferred method of payment is by credit
card. Please register an account on our website at
http://www.cps.ca.gov/ssa/signin.asp. Once you
have successfully registered, you will have the
option to pay by credit card.
9. Any changes you make to your application must
be lined out and initialed.
10. If you require additional space, please use
Section E. Please indicate the section and question
number you are responding to before you identify
additional info.

Form Approved OMB No. 0960-0699
Expires 03/31/2010
Application Fee Statement
**The application fee is generally non-refundable**
Please initial indicating that you have read and understand the statement regarding the application fee:

Initials

Preliminary Questions
1.
2a.
2b.

Are you a licensed or practicing attorney?
Do you have a bachelor’s degree? (If Yes, please skip question 2b. If No,
please answer question 2b.)
Do you have equivalent qualifications? (Only respond if you answered No to
question 2a.)

Yes

Can you pass all aspects of the required background check?

Yes

Have you ever had a felony conviction?

Yes

5.
6.

Have you ever been suspended or disqualified from practice before the Social
Security Administration?
Have you had a judgment or lien assessed against you by a civil court for
malpractice and/or fraud?

In addition, you must submit, before the close of the application period, proof that you have adequate professional liability
insurance or equivalent insurance (such as business liability insurance). For further information see the application
instructions.
Please read the instructions on pages 1 through 3 of this application for eligibility requirements.
If you answered “No” to questions, 2, or 3, you are not eligible for the SSA Non-Attorney Demonstration Project.
If you answered “Yes” to questions 1, 4, 5, or 6, you are not eligible for the SSA Non-Attorney Demonstration Project.
Privacy Act Statement
The information requested on this application is authorized by section 303 of the Social Security Protection Act of 2004
(Public Law 108-203). The information provided will be used to further document your application for participation in the
demonstration project authorized by section 303 and permit a determination about your eligibility to receive direct payment
of fees (from a claimant's past-due benefits) for your representation services. Information requested on this application is
voluntary. However, if you do not provide the required information, a decision based on the evidence in your application
file can result in a determination that you are ineligible for direct payment of fees. While the information you furnish on this
application would almost never be used for any purpose other than making a determination about your eligibility for direct
below
for Administration (SSA) for the following
payment of fees, such information may be disclosed by theSee
Social
Security
purposes (1) to assist SSA in determining your eligibility for
direct
payment
fees (2) to facilitate statistical research and
revised PrivacyofAct
audit activities necessary to assure the integrity and improvement of the demonstration project administered by SSA, and
Statement.
(3) to comply with laws and regulations requiring the exchange of information between SSA and another agency.
Please initial indicating that you have read and understand the Privacy Act Statement:

Initials

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 30 - 60 minutes to read the instructions, gather the facts, and answer
the questions. SEND THE COMPLETED APPLICATION TO CPS HUMAN RESOURCE SERVICES. You may send
comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments
relating to our time estimate to this address.
Replace text
Please initial indicating that you have read and understand the Paperwork Reduction Act Statement:

6401 Security Blvd., Baltimore, MD 21235-6401.
Page 5

Initials

SECTION A

Background Information - Applicant’s Identifying Information

First Name:

Full Middle Name:

Last Name:

Suffix:

Previous Name(s) Used:
Reason(s) for previous name(s) used:
SSN:

Date of Birth (mm/dd/yyyy):

Citizenship Status:
U.S. Citizen

Naturalized Citizen

Alien authorized to
work in the U.S.

Other

If other, please specify:
U.S. Residency Status (if non-citizen):
U.S. Resident

Other (please specify):

Employer Identification Number (EIN),
if applicable:
Taxpayer Identification Number (TIN),
if applicable:
SECTION A

Background Information - Contact Information

Address:

Home Phone:

Address (Line 2):

Mobile Phone:

(
(
City:

State

Zip Code

SECTION A

Yes

)

Work Phone:

(
Would you like to be notified
of the exam via e-mail?

)
)

E-mail Address:

Background Information - Work History

Please provide employer and/or self-employment information for positions held during the past 5 years beginning with the
current or most recent. Please account for all periods of unemployment. For periods of unemployment enter the word
"unemployed" in the Position/Title field and provide From and To Dates only. You must account for the last 5 continuous
years from the date of the application, regardless of its relevance to the demonstration project. Failure to identify all work
within the past 5 years will result in your application being denied as incomplete.
1.

Position/Title

From (mm/yyyy):

To (mm/yyyy):

Position Description:

Name of Employer:
Employer Address:
City:

State:

Name of Supervisor:

Employer Phone:

(
Page 6

Zip Code:

)

SECTION A
2.

Position/Title

Background Information - Work History (Continued)
From (mm/yyyy):

To (mm/yyyy):

Position Description:
Name of Employer:
Employer Address:
City:

State:

Name of Supervisor:

Employer Phone:

(
3.

Position/Title

Zip Code:

)

From (mm/yyyy):

To (mm/yyyy):

Position Description:
Name of Employer:
Employer Address:
City:

State:

Name of Supervisor:

Employer Phone:

(
4.

Position/Title

Zip Code:

)

From (mm/yyyy):

To (mm/yyyy):

Position Description:
Name of Employer:
Employer Address:
City:

State:

Name of Supervisor:

Employer Phone:

(
5.

Position/Title

Zip Code:

)

From (mm/yyyy):

To (mm/yyyy):

Position Description:
Name of Employer:
Employer Address:
City:

State:

Name of Supervisor:

Employer Phone:

(

Page 7

Zip Code:

)

SECTION A
6.

Background Information - Work History (Continued)

Position/Title

From (mm/yyyy):

To (mm/yyyy):

Position Description:
Name of Employer:
Employer Address:
City:

State:

Name of Supervisor:

Employer Phone:

(

Zip Code:

)

If you require additional space, please use Section E or attach supplemental pages available at www.cps.ca.gov/tlc/ssa/resources.asp.

SECTION A

Background Information - Additional Information

1. Have you been admitted to practice law before a court of a State, Territory,
District, or island possession of the United States, or before the Supreme Court
or a lower Federal Court of the United States?
If Yes, please provide the following
information:

Yes

Name of Court:

2. Have you been, by reason of misconduct, disbarred or suspended from any
court or bar to which you were previously admitted to practice?
Details:

If Yes, please state whether you were
disbarred, suspended, or resigned in
lieu of disciplinary proceedings:
3. Have you been, by reason of misconduct, disqualified, sanctioned, or
suspended from participating in any Federal program or appearing before the
Social Security Administration or any other Federal Agency?

Yes

Name of Program or Agency:
Address of Program or Agency:

If Yes, please provide the following
information:

Details of Disqualification, Sanction or Suspension:

Date of disqualification, sanction or suspension:

4. Are you currently being investigated by reason of misconduct, by the Social
Security Administration or any other Federal agency for possible
disqualification, sanction or suspension?

Date of Reinstatement (if applicable):

Yes

Name of Program or Agency:
Address of Program or Agency:

If Yes, please provide the following
information:

Details of Investigation:

Date of Investigation:

Page 8

Status of Investigation:

SECTION A
Background Information - Additional Information (Continued)
5. Have you been determined to have fraudulently used or misused any Social
Yes
Security benefits?
6. Have you been determined to have violated any Social Security program
rules (e.g. rules regarding the disclosure of evidence or representative payee
Yes
rules?

No
No

7. Can you pass all aspects of a Social Security records check?

Yes

8. Have you applied for the SSA Non-Attorney Representative Examination
before?

Yes

Date of Previous Application(s):
Disposition of Previous Application:

If Yes, please provide the following
information:

SECTION B

Any Changes to Report Since Previous Application:

Representation of Claimant Information

Please provide information for 5 Claimants represented within 24 consecutive months during the past 5 years. You may
not list a claimant unless:
• You were the appointed representative of the claimant at the time at which SSA decided the case at any
administrative level (initial, reconsideration, ALJ hearing, Appeals Council); or
• In cases that have not been finally decided, you appeared as the claimant's representative at a hearing before
an ALJ.
1.

Claimant’s First Name

Claimant’s Last Name

Claimants Full SSN:

You will not be required to provide the additional information below if you can provide a copy of any one of the
following that you received as an appointed representative of this claimant during the relevant 24 month period: a
notice of either an initial determination, a reconsideration determination, an ALJ hearing that was held, an ALJ
decision, or an Appeals Council decision.
Are you providing copies of documents to prove representational experience?
Date Appointed (mm/dd/yyyy):

Date Representation Ended (mm/dd/yyyy):

Appeal Level:

Date of Hearing (mm/dd/yyyy):

Did you receive a notice of an initial or reconsideration determination, an ALJ
hearing, or an ALJ or Appeals Council decision as an appointed representative of
the claimant? If so, enter the latest such notice you received and the date you
received it.
Type of Notice:
2.

Yes

Claimant’s First Name

Yes

Notice Date (mm/dd/yyyy):
Claimant’s Last Name

Claimants Full SSN:

Yes

Date Appointed (mm/dd/yyyy):

Date Representation Ended (mm/dd/yyyy):

Appeal Level:

Date of Hearing (mm/dd/yyyy):

Page 9

SECTION B
Representation of Claimant Information (Continued)
Did you receive a notice of an initial or reconsideration determination, an ALJ
hearing, or an ALJ or Appeals Council decision as an appointed representative of
the claimant? If so, enter the latest such notice you received and the date you
received it.
Type of Notice:
3.

Claimant’s First Name

Yes

Notice Date (mm/dd/yyyy):
Claimant’s Last Name

Claimants Full SSN:

Date Representation Ended (mm/dd/yyyy):

Appeal Level:

Date of Hearing (mm/dd/yyyy):

Yes

Claimant’s First Name

Yes

Notice Date (mm/dd/yyyy):
Claimant’s Last Name

Claimants Full SSN:

Date Representation Ended (mm/dd/yyyy):

Appeal Level:

Date of Hearing (mm/dd/yyyy):

Yes

Claimant’s First Name

Yes

Notice Date (mm/dd/yyyy):
Claimant’s Last Name

Claimants Full SSN:

Page 10

SECTION B

Representation of Claimant Information (Continued)

Are you providing copies of documents to prove representational experience?

Yes

Date Appointed (mm/dd/yyyy):

Date Representation Ended (mm/dd/yyyy):

Appeal Level:

Date of Hearing (mm/dd/yyyy):

SECTION C

Yes

Notice Date (mm/dd/yyyy):

Education/Equivalent Qualifications – Colleges/Universities Attended

Please provide information on the accredited Colleges or Universities that you have attended. For each College or
University you enter, you must also provide proof in the form of an official transcript showing the stamp or raised seal, or
otherwise establishing that it is an official copy. If you have a bachelor's degree or higher, you need only enter and
provide proof for the College or University from which you graduated.
If you require additional space, please use Section E or attach supplemental pages available at www.cps.ca.gov/tlc/ssa/resources.asp.
Name of College/University:

City:

Attended From (mm/yyyy):

Attended To (mm/yyyy):

State:

Degree Granted?

Graduate Degree

Yes

Bachelors Degree

At least three (3) years of undergraduate study
Indicate degree granted or years of
study:

At least two (2) years of undergraduate study
At least one (1) year of undergraduate study
Less than one (1) year of undergraduate study

Name of College/University:

City:

Attended To (mm/yyyy):

State:

Degree Granted?

Graduate Degree

Yes

Bachelors Degree

At least three (3) years of undergraduate study
Indicate degree granted or years of
study:

At least two (2) years of undergraduate study
At least one (1) year of undergraduate study
Less than one (1) year of undergraduate study

SECTION C

Education/Equivalent Qualifications – High School Diploma or G.E.D.

If you do not have at least one year of undergraduate study at an accredited College or University, you must
provide information on your High School Diploma or G.E.D. You must also provide proof in the form of a copy of your high
school transcripts, diploma, or G.E.D certificate (or other equivalent documentation).
High School or G.E.D. Institution:
City:

Page 11

State:

Date Diploma or Certificate Awarded (mm/yyyy):

SECTION C

Education/Equivalent Qualifications – Professional Experience

If you have a bachelor's degree or higher, skip this section.
If you do not have a bachelor's degree or higher, provide information on relevant professional experience. The amount of
relevant professional experience you must show varies with the number of years of undergraduate study you have
reported. A certain portion of that experience must be professional level work involving claims under Title II and/or Title
XVI. See the instructions for more information about this requirement. In the Position Description field, you must add
enough detail for SSA to determine if the cited experience constitutes relevant professional experience. If you have any
questions, contact CPS toll free at (800) 376-5728.
1.

This experience is:
Position/Title:

SSA Related Professional Experience

Other Professional Experience

From (mm/yyyy):

To (mm/yyyy):

Position Description:

Name of Employer:
Address:
City:

State

Name of Supervisor:

Employer Phone:

(
2.

This experience is:
Position/Title:

SSA Related Professional Experience

Zip Code:

)

Other Professional Experience

From (mm/yyyy):

To (mm/yyyy):

Position Description:

Name of Employer:
Address:
City:

State

Name of Supervisor:

Employer Phone:

(

Zip Code:

)

If you require additional space, please use Section E or attach supplemental pages available at www.cps.ca.gov/tlc/ssa/resources.asp.

Page 12

SECTION D

Examination Information

The exam will be administered in 6 locations across the country. The exam will be held on the same date at each location.
CPS may cancel any site if enrollment does not meet minimum standards. In that event, applicants will be notified at least
30 days prior to the test date in order to select another active test site and make appropriate travel arrangements. The
following cities are currently planned to host the exam administration:
•
•
•

Austin, Texas
Chicago, Illinois
Nashville, Tennessee

•
•
•

Philadelphia, Pennsylvania
Sacramento, California
Tampa, Florida

Detailed information concerning the specific location of the examination site will be mailed to those applicants determined
eligible to sit for the examination. Visit www.cps.ca.gov for more information.

SECTION D

Examination Information – Location Request

Applicants will be asked to select a first and second choice for their examination site (for use if they meet all of the
prerequisites and are eligible to sit for the exam). Applicants who timely submit their applications but fail to select a
second choice will have their applications denied as incomplete. Applicants who timely submit their applications but repeat
their first choice as their second choice will be contacted and given the opportunity to cure the defect by selecting a second
choice examination site that is different from the first choice examination site. This information will be used by SSA in the
event the first choice examination site is cancelled. Please provide your top two (2) choices for your examination
location.
City:
State:
First Choice Location:
Second Choice Location:

SECTION D

City:

State:

Examination Information – Special Accommodation Request

Please describe any special accommodation you will need at the examination location. Please note that you must provide supporting
documentation from a professional qualified to determine your condition.

Initial indicating that you understand that you must provide written documentation to support your request:

Page 13

Initials

SECTION E

Page 14

Additional Information

Substantial Misrepresentation or Material Discrepancy
If I cannot substantiate my application or it is determined that the information I entered is incorrect, I understand
that I may be determined ineligible for the Demonstration Project, either to begin with or, if I am found eligible,
after I begin to participate in the project.
Please initial indicating that you have read and understand the Substantial Misrepresentation or Material
Discrepancy statement:

Initials

Statement of Understanding
I understand that I must submit my online application, print a copy, sign the copy in ink, include all supporting
documentation along with the application fee, and send or deliver the complete application package to the
address below. I also understand that I will be required to complete, sign and submit a release form necessary
for the criminal background check with this application.
CPS Human Resource Services
Attn: SSA Demonstration Project
241 Lathrop Way
Sacramento, CA 95815
This application package must be postmarked or receipt-dated (if sent by private express service) by midnight
E.D.T. March 16, 2009. If hand-delivered, the application must be received at the above address by 5:00 p.m.
P.D.T. March 16, 2009. I further understand that the application fee is generally non-refundable. CPS will not
process my application until the completed application package, including all supporting documentation, is
received. If this requirement is not met as of midnight E.D.T. March 16, 2009, SSA will process your application as
a denial.
Please initial indicating that you have read and understand the Statement of Understanding statement:

Initials

Penalty of Perjury Statement
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. I understand that
anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes
someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.
Signature (sign in ink):

Page 15

Date:

Form Approved OMB No. 0960-0699
Expires 03/31/2010

Supporting Documentation
Please provide CPS information about your personal professional liability insurance or equivalent insurance
(such as business liability insurance). You must provide a copy of your insurance policy or binder of insurance.
Although providing this information is voluntary, failure to provide the information will cause the Social Security
Administration (SSA) to deny your current application to participate in the demonstration project on direct payment of fees.
Type of Policy:

Coverage:

Policy Number:

Agent Name:

Expiration Date:

Agent Phone:

(

)

Insurance Company:
Address:
City:

State:

Zip Code:

The policy must provide coverage in States in which you do business, and in all States in which you represent
claimants before SSA.

In which state(s) do you represent claimants before SSA?

In which state(s) are you insured to practice before SSA?
Completed Application
Before submitting your completed application package, please verify that you have included:
9
9
9
9
9

A copy of your personal professional liability insurance or equivalent insurance (such as business liability
insurance). You must provide a copy of your insurance policy or certificate of insurance;
If applicable, an official college and/or university transcript(s) showing the stamp or raised seal of the institution, or
otherwise establishing that it is an official copy; *
If applicable, a copy of your high school transcript, diploma, or GED certificate (or other equivalent
documentation);*
If you did not fill out the additional information in the Representation of Claimants section for any claimant you
listed as an individual you represented before SSA, you must send a copy of one of the required notices as
indicated in that section;
You have included a non-refundable certified check, money order, or check drawn from a private firm's account in
the amount of $1,000.00 (in U.S. dollars) payable to CPS Human Resource Services. The preferred method of
payment is by credit card. Please register an account on our website at http://www.cps.ca.gov/ssa/signin.asp.
Once you have successfully registered, you will have the option to pay by credit card.

*Note: for those individuals who have submitted otherwise complete application packages within the application period,
proof of education will be considered timely if it is received by CPS no later than 5:00pm (PDT) on April 23, 2009.
Please mail your completed application and accompanying documents along with your $1,000.00 application fee to:
CPS Human Resource Services
Attn: SSA Demonstration Project
241 Lathrop Way
Sacramento, CA 95815
Page 16

Form Approved OMB No. 0960-0699
Expires 03/31/2010
ACCUSOURCE, INC.
PLEASE READ CAREFULLY
Under section 303 of the Social Security Protection Act of 2004 (2004), the Social Security Administration (SSA), with the assistance
of CPS Human Resource Services (CPS), is conducting a demonstration project on direct payment of representative fees to eligible
non-attorney representatives. SSPA section 303(b) provides that an individual may not be found eligible to participate in the
demonstration project without undergoing a criminal background check to ensure the individual’s fitness to practice before SSA. All
individuals applying to participate in this demonstration project are required to consent to a criminal background check that will be
conducted for SSA and CPS by our firm, ACCUSOURCE, INC. (henceforth, AccuSource). Our address and telephone number are
1240 E. Ontario Avenue, Suite 102-140, Corona, California 92881, 951-734-8882.
APPLICANT AUTHORIZATION FOR RELEASE OF INFORMATION
I authorize AccuSource to conduct a criminal background check in which AccuSource may secure any criminal history information
pertaining to me that may be in the files of any Federal, State, or Local criminal justice agency. I authorize any Federal, State, or
Local criminal justice agency to release to AccuSource any criminal history information pertaining to me that may be in the agency’s
files. I authorize AccuSource, and any of its agents, to disclose orally and in writing the results of this criminal background check to
CPS and SSA.
I understand that the results of the criminal background check may be used by SSA to determine my eligibility for the demonstration
project on direct payment of fees, and may not otherwise be used except as authorized by law. In the event that SSA uses information
from the criminal background check in whole or in part in making an adverse decision with regard to my eligibility to participate in
the project, I understand that CPS will provide me a copy of the report on the criminal background check submitted by AccuSource
and a description in writing of my right to protest the decision to SSA.
I understand that submission of this authorization is voluntary. I also understand that failure to provide the authorization and
information required to conduct a criminal background check will cause SSA to deny my application.
I understand that copies of this authorization that show my signature are as valid as the original, and that this authorization is valid for
6 months from the date signed.
CRIMINAL BACKGROUND CHECK INFORMATION
Applicant Last Name

First Name

Lst Other Names Used

Date of Birth

Middle Name

Please List all the addresses you have lived at in the last 5 years
Current Address

City/State/Zip

Dates

Previous Address

City/State/Zip

Dates

Previous Address

City/State/Zip

Dates

Previous Address

City/State/Zip

Dates

SIGNATURE

Applicant’s Signature

Page 17

Today’s Date

_____________
Daytime Phone

Reporting Changes That Affect Your Social Security Payment – Form SSA-1425
Privacy Act Statement
Collection and Use of Personal Information
Sections 202, 203, and 205 of the Social Security Act, as amended (42 U.S.C. 402,
403, and 405) authorizes us to collect this information. We will us the information
you provide to assist us in determining your continuing eligibility to benefits or your
benefit amount. The information you provide on this form is voluntary. However,
failure to provide all or part of the requested information could prevent us from
making an accurate and timely decision on your claim or could result in the loss of
benefits.
We rarely use the information you provide on this form for any purpose other than for
the reasons explained above. 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, General
Services Administration, National Archives Records Administration, and the
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 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 and administered benefit
programs for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of
Records Notice entitled, Claims Folder System, 60-0089. This notice, additional
information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at your local Social
Security office.

File Type	application/pdf
File Title	Microsoft Word - SSA Candidate Application _2009 Version_.doc
Author	emarshall
File Modified	2009-10-21
File Created	2009-10-21