Form SSA-1696-U4 Appointment of Representative

COMPLETING THIS FORM TO APPOINT A REPRESENTATIVE
Choosing to be Represented
You can choose to have a representative help you when
you do business with Social Security. We will work with
your representative, just as we would with you. It is
important that you select a qualified person because, once
appointed, your representative may act for you in most
Social Security matters. We give more information, and
examples of what a representative may do, in the section
titled “Information for Claimants.”

See revised
Privacy Act
Collection and Use of Personal Information
Statement
Sections 206(a) and 1631(d)
of the Socialbelow.
Security Act, as
Privacy Act Statement

amended, authorize us to collect this information. We will
use the information you provide on this form to verify
your appointment of an individual as your representative
and his or her acceptance of the appointment.
Completion of this form is voluntary; however, if you
want to use this form to appoint someone to act on your
behalf in matters before the Social Security
Administration (SSA), then you and that individual must
complete the appropriate sections of this form.
We rarely use the information you supply for any purpose
other than to verify your appointment of an individual as
your representative and his or her acceptance of the
appointment. 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:

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. A complete list of routine uses
for this information is available in our System of
Records Notice entitled “Appointed Representative
File” (60-0325). The notice, additional information
regarding this form, routine uses of information, and
our programs and systems are available on-line
at www.socialsecurity.gov or at your local Social
Security office.
With your permission, your representative may
designate an associate or other party to request and
receive information from your claim file on your
representative's behalf.
For more information about this privacy statement
and how information you provide to us may be used
or disclosed to others please contact any Social
Security office.
How to Complete this Form
Please print or type your answers on this form. At the
top of the form, provide your full name and your Social
Security number. If your claim is based on another
person's work and earnings, also provide the “wage
earner's” name and Social Security number. If you
appoint more than one individual as your representative,
you may want to complete a form for each of them.
Part I Claimant’s Appointment of Representative

1.

To enable a third party or an agency to assist
Social Security in establishing right 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 or 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 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.

Give the name and address of the individual(s) you are
appointing. You may appoint an attorney or any other
qualified individual to represent you. You also may
appoint more than one individual, but please refer to the
“Information for Claimants” section “What your
Representative(s) May Charge” for more information
about payment of fees. You can appoint one or
more individuals in a firm, corporation, or other
organization as your representative(s), but you may not
appoint a law firm, legal aid group, corporation or
organization itself.
Check the block(s) showing the program(s) under which
you have a claim. You may check more than one block.
Check:
•
Title II (RSDI), if your claim concerns retirement,
survivors, or disability insurance benefits.
Title
XVI (SSI), if your claim concerns
•
Supplemental Security Income.
Title XVIII (Medicare Coverage), if your claim
•
concerns entitlement to Medicare or enrollment in
the Supplementary Medical Insurance (SMI) plan.
•

Title VIII (SVB), if your claim concerns
entitlement to Special Veterans Benefits.

When you give your permission your representative may
designate an associate (e.g. a clerk), or other party (e.g. a
copying service) to receive information from your claim
file on your representative's behalf for the duration of
your claim. If you want to give your representative
permission to do that, check the block to authorize this
release.
If you will have more than one representative, check the
appropriate block and give the name of the individual
you want to be your principal representative. SSA will
make contacts with, and send notices or requests for
development to, only the principal representative. The
principal representative will provide copies of notices or
requests to other co-representatives.
You must sign and date the form. Print or type your
address, area code and telephone number.
If you are appointing a representative to replace a
representative that you discharged or who withdrew his
or her representation, you must notify us in writing that
the prior appointment has ended.
Part II Representative’s Acceptance of Appointment
Each individual you appoint in Part I should also
complete Part II. If the individual is not an attorney, he
or she must give his or her name, state that he or she
accepts the appointment, and sign the form.
Part III Fee Arrangement
To help in processing benefits and fee payments timely
you and your representative should complete this
section. Your representative should check a box, sign
and date the form. Your representative may choose to
receive payment, waive direct payment, or waive
payment of the fee altogether. If you and your
representative change your arrangement before we
decide your claim, you can provide a new or amended
form so that we can update our records. If you appoint a
second representative or co-counsel who also will not
charge a fee, he or she should also complete this part or
provide a new form, or if not using the form, give us a
separate, written waiver statement. If your representative
is not eligible for direct payment, or is an attorney or an
eligible non-attorney who waives direct payment, you
will be responsible for paying any fee we authorize.

Form SSA-1696-U4 (xx-20xx ) ef (xx-xx)

Under certain circumstances, we do not have to
authorize the fee. These circumstances include where a
Court has awarded a fee based on your representative's
actions as a legal guardian or court-appointed
representative, or where a business (such as an
insurance company), other organization or government
agency will pay your representative's fee and you and
your beneficiaries have no liability to pay any fees or
expenses.
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 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 (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.

References
•

18 U.S.C. §§ 203, 205, and 207; and 42 U.S.C. §§
406 (a), 1320a-6, and 1383(d)(2)

•

20 CFR §§ 404.1700 et. seq., 408.1101, and
416.1500 et. seq.

•

Social Security Rulings 83-27 and 82-39

•

26 U.S.C. §§ 6041 and 6045(f)

INFORMATION FOR REPRESENTATIVES
Fees for Representation
An attorney or other individual who wants to charge
or collect a fee for providing services in connection
with a claim before the Social Security
Administration (SSA) must generally obtain our
prior authorization of the fee for representation. The
only exceptions are if:
•

certain requirements are met and a third-party
entity, such as a business, an insurance carrier,
a for profit, or nonprofit organization or a
government agency will pay the fee and any
expenses from its own funds and the claimant
and auxiliary beneficiaries incur no liability,
directly or indirectly, for the cost(s); or

•

a Federal court awarded a fee based on the
representative's activities as the claimant's
legal guardian or court-appointed
representative; or

•

a Federal court awarded a fee for
representational services provided before the
court. In those cases, neither the Federal court
nor SSA can authorize a fee for the other.

Obtaining Authorization of a Fee
To charge a fee for services, you must use one of
two mutually exclusive fee authorization processes.
You must file either a fee petition or a fee
agreement with us. In either case, you cannot
charge more than the fee amount we

Fee Agreement Process
If you and the claimant have a written fee agreement, one of
you must give it to us before we decide the claim(s). We
usually will approve the agreement if:
•
•

•
•

you both signed it;
the fee you agreed on is no more than 25
percent of past-due benefits, or $6,000 (or a
higher amount we set and announce in the
Federal Register), whichever is less;
we approve the claim(s); and
the claim results in past-due benefits.

We will send you a copy of the notice we send the claimant
telling him or her the amount of the fee you can charge
based on the agreement.
If we do not approve the fee agreement, we will tell you in
writing. We also will tell you and the claimant that you must
file a fee petition if you wish to charge and collect a fee.
After we tell you the amount of the fee you can charge, you
or the claimant may ask us in writing to review the
authorized fee. If we approved a fee agreement, the person
who decided the claim(s) also may ask us to lower the
amount. Someone who did not decide the amount of the fee
the first time will review and finally decide the amount of the
fee.

authorize. Fee Petition Process

Collecting a Fee

You may file a fee petition after you complete your
services to the claimant. This written request must
describe in detail the amount of time you spent on
each service provided and the amount of the fee you
are requesting. In order to directly pay you under a
fee petition, you must either file a fee petition or
notify us within 60 days after we decide the claim
of your intent to file a fee petition.

You may accept money for your fee in advance, as long as
you hold it in a trust or escrow account. The claimant never
owes you more than the fee we authorize, except for:

You must give the claimant a copy of the fee
petition and each attachment. The claimant may
disagree with the information shown by contacting
a Social Security office within 20 days of receiving
his or her copy of the fee petition. We will consider
the reasonable value of the services provided and
send you notice of the amount of the fee you can
charge.

•

any fee a Federal court allows for your services before it;
and

•

out-of-pocket expenses you incur or expect to incur, for
example, the cost of getting evidence. Our authorization
is not needed for such expenses.

If you are not an attorney and you are ineligible to
receive direct payment, you must collect the authorized fee
from the claimant. If you are interested in becoming eligible
to receive direct payment, you can find more information
about this on our “Representing Social Security Claimants”
website:
http://www.ssa.gov/representation/.

If you are an attorney or a non-attorney whom
SSA has found eligible to receive direct payment and
you register with SSA, as described below, we
usually withhold 25 percent of any past-due benefits
that result from a favorably decided retirement,
survivors, disability insurance, or supplemental
security income claim. Once we authorize a fee, we
pay you all or part of the fee from the funds
withheld. We will also charge you the assessment
required by section 206(d) and 1631(d)(2)(C) of the
Social Security Act. You cannot charge or collect
this expense from the claimant. You will need to
collect from the claimant:
•

•

the rest of the fee he or she owes, if the
amount of the authorized fee is more than the
amount of money we withheld and paid you for
the claimant, plus any amount you held for the
claimant in a trust or escrow account.
all of the fee he or she owes, if we did not
withhold past-due benefits, (for example,
because there are no past-due benefits; you
waived direct payment or did not register for
direct payment; the claimant discharged you or
you withdrew from representing before we
issued a favorable decision); or we withheld
past-due benefits, but you did not ask us to
authorize a fee or tell us that you planned to
ask for a fee within 60 days after the date of the
notice of award and we released the withheld
amount to the claimant.

Registering for Direct Fee Payment
If you are eligible and want to receive direct payment, you
must register with us before we effectuate a favorable
decision on the claim. To register, you must submit a Form
SSA-1699 (Registration of Individuals and Staff for
Appointed Representative Services) once and a Form
SSA-1695 (Identifying Information for Possible Direct
Payment of Authorized Fees) with each appointment. We
will use the information you provide on these forms to issue
you a Form 1099-MISC if we pay you aggregate fees of
$600 or more in a calendar year. The Internal Revenue
Code requires that we do this. For information on the
registration process, see our “Representing Social
Security Claimants”
website http://www.ssa.gov/representation/.
Conflict of Interest and Penalties
If you commit improper acts, you can be suspended or
disqualified from representing anyone before SSA. You
also can face criminal prosecution. Improper acts include:
•

If you are or were an officer or employee of the
United States, providing services as a representative
in certain claims against and other matters affecting
the Federal government.

•

Knowingly and willingly furnishing false information.

•

Charging or collecting an unauthorized fee, or charging
or collecting too much for services provided in any
claim, including services before a court that made a
favorable decision.
References

• 18 U.S.C. §§ 203, 205, and 207; and 42 U.S.C. §§ 406
(a), 1320a-6, and 1383(d)(2)
• 20 CFR §§ 404.1700 et. seq., 408.1101, and 416.1500 et.
seq.
• Social Security Rulings 83-27 and 82-39
• 26 U.S.C. §§ 6041 and 6045(f)

Form SSA-1696-U4 (xx-20xx ) ef (xx-x)

Social Security Administration

Form Approved
OMB No. 0960-0527

Please read the instructions before completing this form.
Name (Claimant) (Print or Type)

Social Security Number

Wage Earner (If Different)

Social Security Number

Part I
I appoint this individual,

CLAIMANT’S APPOINTMENT OF REPRESENTATIVE
(Name and Address)

to act as my representative in connection with my claim(s) or asserted right(s) under:
Title XVI (SSI)
Title XVIII (Medicare)
Title VIII (SVB)

Title II (RSDI)

This individual may, entirely in my place, make any request or give any notice; give or draw out evidence or
information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I authorize the Social Security Administration to release information about my pending claim(s) or asserted
right(s) to designated associates who perform administrative duties (e.g. clerks), partners, and/or parties
under contractual arrangements (e.g. copying services) for or with my representative.
I appoint, or I now have, more than one representative. My principal representative
is _______________________________________________________________________________
(Name of Principal Representative)

Signature (Claimant)

Address
Fax Number (with Area Code)

Telephone Number (with Area Code)

(

)

Part II

Date

(
)
REPRESENTATIVE’S ACCEPTANCE OF APPOINTMENT

, hereby accept the above appointment. I certify that I have
I,
not been suspended or prohibited from practice before the Social Security Administration; that I am not
disqualified from representing the claimant as a current or former officer or employee of the United States; and
that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has
been approved in accordance with the laws and rules referred to on the reverse side of the representative's
copy of this form. If I decide not to charge or collect a fee for the representation, I will notify the Social Security
Administration. (Completion of Part III satisfies this requirement.)
Check one:
I am an attorney.
I am a non-attorney eligible for direct payment under SSA law.
I am a non-attorney not eligible for direct payment.
I am now or have previously been disbarred or suspended from a court or bar to which I was previously
admitted to practice as an attorney.
YES
NO
I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.

YES

NO

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.

Signature (Representative)

Address

Telephone Number (with Area Code)

Fax Number (with Area Code)

(

)

Part III

Date

(
)
FEE ARRANGEMENT

(Select an option, sign and date this section.)
I am charging a fee and requesting direct payment of the fee from withheld past-due benefits. (SSA must authorize the
fee unless a regulatory exception applies.)
I am charging a fee but waiving direct payment of the fee from withheld past-due benefits --I do not qualify for or do
not request direct payment, or I will bill the claimant, or a third-party individual will pay the fee. (SSA must authorize the
fee unless a regulatory exception applies. )
I am waiving fees and expenses from the claimant and any auxiliary beneficiaries --By checking this block I certify that
my fee will be paid by a third-party entity or government agency, and that the claimant and any auxiliary beneficiaries are free
of all liability, directly or indirectly, in whole or in part, to pay any fee or expenses to me or anyone as a result of their claim(s)
or asserted right(s). (SSA does not need to authorize the fee if a third-party entity or a government agency will pay from its
funds the fee and any expenses for this appointment. )
I am waiving fees from any source--I am waiving my right to charge and collect any fee, under sections 206 and
1631(d)(2) of the Social Security Act. I release my client and any auxiliary beneficiaries from any obligations, contractual or
otherwise, which may be owed to me for services provided in connection with their claim(s) or asserted right(s).

Signature (Representative)
Form SSA-1696-U4 (xx-20xx) ef (xx-20xx)

Date
FILE COPY

Social Security Administration
Please read the instructions before completing this form.
Social Security Number
Name (Claimant) (Print or Type)
Social Security Number

Wage Earner (If Different)
Part I
I appoint this individual,

Form Approved
OMB No. 0960-0527

CLAIMANT’S APPOINTMENT OF REPRESENTATIVE
(Name and Address)

to act as my representative in connection with my claim(s) or asserted right(s) under:
Title II (RSDI)
Title XVI (SSI)
Title XVIII (Medicare)

Title VIII (SVB)

This individual may, entirely in my place, make any request or give any notice; give or draw out evidence or
information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I authorize the Social Security Administration to release information about my pending claim(s) or asserted
right(s) to designated associates who perform administrative duties (e.g. clerks), partners, and/or parties
under contractual arrangements (e.g. copying services) for or with my representative.
I appoint, or I now have, more than one representative. My principal representative
is ______________________
______________________
_________________________ ___
(Name of Principal Representative)

Signature (Claimant)

Address

Telephone Number (with Area Code)

Fax Number (with Area Code)

(

)

Part II

Date

(
)
REPRESENTATIVE’S ACCEPTANCE OF APPOINTMENT

, hereby accept the above appointment. I certify that I
I,
have not been suspended or prohibited from practice before the Social Security Administration; that I am not
disqualified from representing the claimant as a current or former officer or employee of the United States; and
that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has
been approved in accordance with the laws and rules referred to on the reverse side of the representative's
copy of this form. If I decide not to charge or collect a fee for the representation, I will notify the Social Security
Administration. (Completion of Part III satisfies this requirement.)
Check one:
I am an attorney.
I am a non-attorney eligible for direct payment under SSA law.
I am a non-attorney not eligible for direct payment.
I am now or have previously been disbarred or suspended from a court or bar to which I was previously
admitted to practice as an attorney.
NO
YES
I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.
YES
NO
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.

Signature (Representative)

Address

Telephone Number (with Area Code)

Fax Number (with Area Code)

(

)

Part III

Date

(
)
FEE ARRANGEMENT

(Select an option, sign and date this section.)
I am charging a fee and requesting direct payment of the fee from withheld past-due benefits. (SSA must authorize
the fee unless a regulatory exception applies.)
I am charging a fee but waiving direct payment of the fee from withheld past-due benefits —I do not qualify for or
do not request direct payment, or I will bill the claimant, or a third-party individual will pay the fee. (SSA must
authorize the fee unless a regulatory exception applies.)
I am waiving fees and expenses from the claimant and any auxiliary beneficiaries —By checking this block I certify
that my fee will be paid by a third-party entity or a government agency, and that the claimant and any auxiliary beneficiaries
are free of all liability, directly or indirectly, in whole or in part, to pay any fee or expenses to me or anyone as a result of
their claim(s) or asserted right(s). (SSA does not need to authorize the fee if a third-party entity or a government agency will
pay from its funds the fee and any expenses for this appointment.)
I am waiving fees from any source—I am waiving my right to charge and collect any fee, under sections 206 and
1631(d)(2) of the Social Security Act. I release my client and any auxiliary beneficiaries from any obligations, contractual or
otherwise, which may be owed to me for services provided in connection with their claim(s) or asserted right(s).

Signature (Representative)
Form SSA-1696-U4 (xx-20xx) ef (xx-20xx)

Date
CLAIMANT COPY

INFORMATION FOR CLAIMANTS
What Your Representative(s) May Do
We will work directly with your appointed representative unless he or
she asks us to work directly with you. Your representative may:

•
•

•
•
•
•

get information from your claim(s) file;
with your permission, designate associates who perform
administrative duties (e.g. clerks), partners and/or parties under
contractual arrangements (e.g., copying services) to receive
information from us on his or her behalf (by checking the
appropriate block and signing this form, you are providing your
permission for your representative to designate such associates,
partners, and/or contractual parties);
give us evidence or information to support your claim;
come with you, or for you, to any interview, conference, or
hearing you have with us;
request a reconsideration, a hearing, or Appeals Council
review; and
help you and your witnesses prepare for a hearing and
question any witnesses.

Also, your representative will receive a copy of the decision(s) we
make on your claim(s). We will rely on your representative to tell
you about the status of your claim(s), but you still may call or visit us
for information.
You and your representative(s) are responsible for giving Social
Security accurate information. It is wrong to knowingly and willingly
furnish false information. Doing so may result in criminal prosecution.
We usually continue to work with your representative until (1) you
notify us in writing that he or she no longer represents you; or (2)
your representative tells us that he or she is withdrawing or indicates
that his or her services have ended (for example, by filing a fee
petition or not pursuing an appeal). We do not continue to work with
someone who is suspended or disqualified from representing
claimants. We will inform you if we suspend your representative.

What Your Representative(s) May Charge
Each representative you appoint can ask for a fee. To charge you a
fee for services, your representative must get our authorization if you
or another individual will pay the fee. However, as described in
“Completing this form to appoint a representative, Part III Fee
Arrangement” section of this form, under certain circumstances, we
do not have to authorize the representative's fee. To request a fee,
your representative must file a fee agreement or a fee petition. In
either case, your representative cannot charge you more than the fee
amount we authorize. If he or she does, promptly report this to your
Social Security office.
Filing A Fee Petition
Your representative may file a fee petition when his or her work on
your claim(s) is complete. This written request describes in detail the
amount of time your representative spent on each service he or she
provided you. The request also gives the amount of the fee the
representative wants to charge for these services. Your representative
must give you a copy of the fee petition and each attachment. If you
disagree with the information shown in the fee petition, contact your
Social Security office. Please do this within 20 days of receiving your
copy of the petition.
We will review the petition and consider the reasonable value of the
services provided. Then we will tell you in writing the amount of the
fee we authorize.

Form SSA-1696-U4 (xx-20xx ) ef (xx-x)

Filing A Fee Agreement
If you and your representative have a written fee agreement, one of
you must give it to us before we decide your claim(s). We usually
will approve the agreement if:
• you both signed it;
• the fee you agreed on is no more than 25 percent of past-due
benefits, or $6,000 (or a higher amount we set and announced
in the Federal Register), whichever is less;
• we approve your claim(s); and
• your claim results in past-due benefits.
We will tell you in writing the amount of the fee your representative
can charge based on the agreement.
If we do not approve the fee agreement, we will tell you and your
representative in writing. If your representative wishes to charge and
collect a fee, he or she must file a fee petition.
After we tell you the amount of the fee your representative can
charge, you or your representative can ask us to look at it again if
either or both of you disagree with the amount. If we approved a fee
agreement, the person who decided your claim(s) also may ask us to
lower the amount. Someone who did not decide the amount of the
fee the first time will review and finally decide the amount of the fee.

How Much You Pay
You never owe more than the fee we authorize, except for:
• any fee a Federal court allows for your representative's services
before it; and
• out-of-pocket expenses your representative incurs or expects to
incur, for example, the cost of getting your doctor's or hospital's
records. Our authorization is not needed for such expenses.
Your representative may accept money in advance as long as he or
she holds it in a trust or escrow account. We usually withhold 25
percent of your past-due benefits to pay toward the fee for you if:
• your retirement, survivors, disability insurance, and/or
supplemental security income claim(s) results in past-due
benefits;
• your representative is an attorney or a non-attorney whom we
have determined to be eligible to receive direct payment of fees;
and
• your representative registers with us for direct payment before
we effectuate a favorable decision on your claim.
You must pay your representative directly:

•

•

the rest of the fee you owe, if the amount of the authorized fee
is more than the money we withheld and paid to your
representative for you plus any amount your representative held
for you in a trust or escrow account.
all of the fee you owe, if we did not withhold past-due benefits,
(for example, because there are no past-due benefits; your
representative waived direct payment, did not register for direct
payment, you discharged the representative, or he or she
withdrew from representing you, before we issued a favorable
decision); or we withheld an amount from your past-due benefits,
but your representative did not ask us to authorize a fee or tell us
that he or she planned to ask for a fee within 60 days after the
date of your notice of award and we released the withheld
amount to you.

Social Security Administration

Form Approved
OMB No. 0960-0527

Please read the instructions before completing this form.
Social Security Number
Name (Claimant) (Print or Type)
Social Security Number

Wage Earner (If Different)
Part I
I appoint this individual,

CLAIMANT’S APPOINTMENT OF REPRESENTATIVE
(Name and Address)

to act as my representative in connection with my claim(s) or asserted right(s) under:
Title II (RSDI)
Title XVI (SSI)
Title XVIII (Medicare)

Title VIII (SVB)

This individual may, entirely in my place, make any request or give any notice; give or draw out evidence or
information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I authorize the Social Security Administration to release information about my pending claim(s) or asserted
right(s) to designated associates who perform administrative duties (e.g. clerks), partners, and/or parties
under contractual arrangements (e.g. copying services) for or with my representative.
I appoint, or I now have, more than one representative. My principal representative
is ________________________________________________________________________________
(Name of Principal Representative)

Signature (Claimant)

Address

Telephone Number (with Area Code)

Fax Number (with Area Code)

(

)

Part II

Date

(
)
REPRESENTATIVE’S ACCEPTANCE OF APPOINTMENT

, hereby accept the above appointment. I certify that I
I,
have not been suspended or prohibited from practice before the Social Security Administration; that I am not
disqualified from representing the claimant as a current or former officer or employee of the United States; and
that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has
been approved in accordance with the laws and rules referred to on the reverse side of the representative's
copy of this form. If I decide not to charge or collect a fee for the representation, I will notify the Social Security
Administration. (Completion of Part III satisfies this requirement.)
Check one:
I am an attorney.
I am a non-attorney eligible for direct payment under SSA law.
I am a non-attorney not eligible for direct payment.
I am now or have previously been disbarred or suspended from a court or bar to which I was previously
admitted to practice as an attorney.
NO
YES
I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.
YES
NO
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.

Signature (Representative)

Address

Telephone Number (with Area Code)

Fax Number (with Area Code)

(

)

Part III

Date

(
)
FEE ARRANGEMENT

(Select an option, sign and date this section.)
I am charging a fee and requesting direct payment of the fee from withheld past-due benefits. (SSA must authorize
the fee unless a regulatory exception applies.)
I am charging a fee but waiving direct payment of the fee from withheld past-due benefits —I do not qualify for or
do not request direct payment, or I will bill the claimant, or a third-party individual will pay the fee. (SSA must authorize
the fee unless a regulatory exception applies.)
I am waiving fees and expenses from the claimant and any auxiliary beneficiaries —By checking this block I certify
that my fee will be paid by a third-party entity or government agency, and that the claimant and any auxiliary beneficiaries
are free of all liability, directly or indirectly, in whole or in part, to pay any fee or expenses to me or anyone as a result of
their claim(s) or asserted right(s). (SSA does not need to authorize the fee if a third-party entity or a government agency will pay from
its funds the fee and any expenses for this appointment. )

I am waiving fees from any source—I am waiving my right to charge and collect any fee, under sections 206 and
1631(d)(2) of the Social Security Act. I release my client and any auxiliary beneficiaries from any obligations, contractual or
otherwise, which may be owed to me for services provided in connection with their claim(s) or asserted right(s).

Signature (Representative)
Form SSA-1696-U4 (xx-20xx) ef (xx-20xx)

Date
REPRESENTATIVE COPY

Social Security Administration

Form Approved
OMB No. 0960-0527

Please read the instructions before completing this form.
Social Security Number
Name (Claimant) (Print or Type)
Social Security Number

Wage Earner (If Different)
Part I
I appoint this individual,

CLAIMANT’S APPOINTMENT OF REPRESENTATIVE
(Name and Address)

to act as my representative in connection with my claim(s) or asserted right(s) under:
Title II (RSDI)
Title XVI (SSI)
Title XVIII (Medicare)

Title VIII (SVB)

This individual may, entirely in my place, make any request or give any notice; give or draw out evidence or
information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I authorize the Social Security Administration to release information about my pending claim(s) or asserted
right(s) to designated associates who perform administrative duties (e.g. clerks), partners, and/or parties
under contractual arrangements (e.g. copying services) for or with my representative.
I appoint, or I now have, more than one representative. My principal representative
is
__________________________________________________________________________
(Name of Principal Representative)

Signature (Claimant)

Address

Telephone Number (with Area Code)

Fax Number (with Area Code)

(

)

Part II

Date

(
)
REPRESENTATIVE’S ACCEPTANCE OF APPOINTMENT

, hereby accept the above appointment. I certify that I
I,
have not been suspended or prohibited from practice before the Social Security Administration; that I am not
disqualified from representing the claimant as a current or former officer or employee of the United States; and
that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has
been approved in accordance with the laws and rules referred to on the reverse side of the representative's
copy of this form. If I decide not to charge or collect a fee for the representation, I will notify the Social Security
Administration. (Completion of Part III satisfies this requirement.)
Check one:
I am an attorney.
I am a non-attorney eligible for direct payment under SSA law.
I am a non-attorney not eligible for direct payment.
I am now or have previously been disbarred or suspended from a court or bar to which I was previously
admitted to practice as an attorney.
NO
YES
I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.
YES
NO
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.

Signature (Representative)

Address

Telephone Number (with Area Code)

Fax Number (with Area Code)

(

)

Part III

Date

(
)
FEE ARRANGEMENT

(Select an option, sign and date this section.)
I am charging a fee and requesting direct payment of the fee from withheld past-due benefits. (SSA must authorize
the fee unless a regulatory exception applies.)
I am charging a fee but waiving direct payment of the fee from withheld past-due benefits —I do not qualify for or
do not request direct payment, or I will bill the claimant, or a third-party individual will pay the fee. (SSA must authorize
the fee unless a regulatory exception applies.)
I am waiving fees and expenses from the claimant and any auxiliary beneficiaries —By checking this block I certify
that my fee will be paid by a third-party entity or government agency, and that the claimant and any auxiliary beneficiaries
are free of all liability, directly or indirectly, in whole or in part, to pay any fee or expenses to me or anyone as a result of
their claim(s) or asserted right(s). (SSA does not need to authorize the fee if a third-party entity or a government agency
will pay from its funds the fee and any expenses for this appointment.)
I am waiving fees from any source—I am waiving my right to charge and collect any fee, under sections 206 and
1631(d)(2) of the Social Security Act. I release my client and any auxiliary beneficiaries from any obligations, contractual or
otherwise, which may be owed to me for services provided in connection with their claim(s) or asserted right(s).

Signature (Representative)
Form SSA-1696-U4 ( xx-20xx) ef (xx -20xx)

Date
ODAR COPY

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 verify your appointment of
an individual as your representative and his or her acceptance of the appointment.
Furnishing us this information is voluntary. However, if you want to use this form to appoint
someone to act on your behalf in matters before the Social Security Administration (SSA), then
you and that individual must complete the appropriate sections of this form.
We rarely use the information you supply for any purpose other than to verify your appointment
of an individual as your representative and his or her acceptance of the appointment. However,
we may use the information for the administration of our programs including sharing
information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice entitled, Appointed Representative File,
60-0325. Additional information about this and other system of records notices and our
programs are available from our Internet website at www.socialsecurity.gov or at your local
Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.