SSA-1695 Current Version

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 Social Security Number (if different)
_
_

Wage Earner's Name (if different than above)

Title II (RSDI)

Type of Benefits

Social Security Number
_
_

Title XVI (SSI)

Information about You, the Representative

Name

Social Security Number
_

City

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

Country

ZIP Code or Postal Zone

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

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-F3 (11-2010)
Destroy Prior Editions

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.

Form SSA-1695-F3 (11-2010)

Page 2

Privacy Act Notice
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 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 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.
Form SSA-1695-F3 (11-2010)

Page 3