SSA-1696 Current Version

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.”

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.
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:
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 or the Department of
Veterans Affairs);

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 Appointment of Representative
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:
o Title II (RSDI), if your claim concerns retirement, survivors, or
disability insurance benefits.
o Title XVI (SSI), if your claim concerns Supplemental Security
Income.
o Title XVIII (Medicare Coverage), if your claim concerns
entitlement to Medicare or enrollment in the Supplementary
Medical Insurance (SMI) plan.
o Title XVIII (SVB), if your claim concerns entitlement to Special
Veterans Benefits.

3.

To make determinations for eligibility in similar health and
income maintenance programs at the Federal, State, and
local level; and,

When you give your permission your representative may designate an
associate (e.g. a clerk), or other party or entity (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.

4.

To facilitate statistical research, audit, or investigative
activities necessary to assure the integrity and improvement
of Social Security programs.

If you will have more than one representative, check the appropriate
block and give the name of the individual you want to be your main
representative.

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.

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 Acceptance of Appointment
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.

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. 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 212356401. 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. and 416.1500 et. seq.
Social Security Rulings 83-27 and 82-39
26 U.S.C. §§ 6041 and 6045(f)

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.

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.

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 courtappointed representative;
•
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.

not decide the amount of the fee the first time will review and
finally decide the amount of the fee.

Collecting a Fee
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:
•
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 Claimants”
website: http://www.ssa.gov/representation/.

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 authorize.

Fee Petition Process
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 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.

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 pastdue 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

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 pastdue 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 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. and 416.1500 et. seq.
Social Security Rulings 83-27 and 82-39
26 U.S.C. §§ 6041 and 6045(f)

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
APPOINTMENT OF REPRESENTATIVE
I appoint this person, ____________________________________________________________,
(Name and Address)
to act as my representative in connection with my claim(s) or asserted right(s) under:
 Title II
 Title XVI
 Title XVIII
 Title VIII
(RSDI)
(SSI)
(Medicare Coverage)
(SVB)
This person 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 main representative is:
_________________________________________________________________________
(Name of Principal Representative)

Signature (Claimant)

Address

Telephone Number (with Area Code)
(
)
-

Fax Number (with Area Code)
(
)
-

Date

Part II
ACCEPTANCE OF APPOINTMENT
I, __________________________, hereby accept the above appointment. I certify that I have not been suspended or
prohibited from practice before the Social Security Administration; I am not disqualified from representing the
claimant as a current or former officer or employee of the United States; and I will not charge or collect any fee from
the claimant, his or her auxiliaries, or a third-party individual unless it has been authorized in accordance with the
laws and rules referred to on the reverse side of the representative’s copy of this form or a regulatory exception
applies. If I decide not to charge or collect any 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)
(
)
-

Date

Part III

FEE ARRANGEMENT
(Select an option, sign and date this section.)
 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.)

 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. (SSA must authorize the fee unless a regulatory exception applies.)
 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, 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. Do not check this block if a third-party individual will pay the fee.)

 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)

Date

Form SSA-1696-U4 (1-2010) (EF 1-2010) Destroy Prior Editions