Form SSA-1691 Eligible Non-Attorney Representative

Social Security Administration
Eligible Non-Attorney Representative

OMB No. 0960-0699

You must complete this application carefully and provide all supporting documentation as required. You must provide all
required information once you pass the examination in order to receive direct payment of fees. If you have any
questions, please access the Attorneys and Appointed Representatives Website at http://www.ssa.gov/representation/.

Purpose of this Form
Section 3 of the Social Security Disability
Applicants’ Access to Professional
Representation Act (PRA) Public Law no.111142 provides for permanent extension of direct
payment of SSA-approved fees to certain nonattorney representatives. Under the PRA, to be
eligible for direct payment of fees, a nonattorney representative must fulfill the following
statutory prerequisites: (1) possess a
bachelor’s 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.
SSA must collect the requested information to
determine if a non- attorney representative
has met the prerequisites 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.
Application Fee
PRA section 3(a) provides that the
Commissioner may assess applicants a
reasonable fee to cover the costs of
administering the prerequisites process. The
non-refundable fee is listed on the Attorneys
and Appointed Representatives Website at
http://www.ssa.gov/representation/;
Applicants must include the non-refundable fee
payment with their application package;

Form SSA-1691

Acceptable forms of fee payment will be by
check, money order, or a check drawn from a
private firm's account;
Applicants will pay their fees to the entity
listed on the Attorneys and Appointed
Representatives Website at
http://www.ssa.gov/representation/; and
Applicants found ineligible to take the
examination or who fail the examination may
apply in any future application period, but must
then again pay the full fee.
Education and Equivalent Qualifications
A bachelor’s degree from an accredited
institution of higher education is a prerequisite
to receive direct payment of fees. Applicants
who do not have a bachelor’s degree may
satisfy this prerequisite based on a
combination of holding a high school diploma
or general education diploma (GED) plus four
years of relevant professional experience that
the Commissioner determines to be equivalent
to a bachelor’s degree.
Relevant professional experience is training or
work through which the applicant
demonstrates 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. Professional work
involving claims for benefits under title II or
title XVI of the Act is considered relevant
professional experience.
An applicant must submit proof of a
bachelor’s degree or equivalent
qualifications after he or she passes the
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examination. Failure to do so precludes the
applicant from establishing his or her eligibility
to receive direct payment of fees. Proof of
education is an official transcript showing the
stamp or raised seal. Proof of relevant
professional experience includes, but is not
limited to an Internal Revenue Service (IRS)
Form W-2(s), Wage and Tax Statement(s),
and letters from employers.
Attorneys who have fees paid directly from
their clients' past-due benefits pursuant to
sections 206 and 1631(d)(2) of the Act are not
required to take the examination. Attorneys who
are suspended or disbarred by a State or
Federal court or disqualified from appearing
before a Federal agency or program are not
eligible to receive direct payment and should not
submit an application.
Types of Insurance
Applicants 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. The 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.
See the Attorneys and Appointed
Representatives Website at
http://www.ssa.gov/representation/ for
professional and business liability insurance
coverage amounts.
An applicant must submit proof of the
required insurance after he or she passes the
examination. Failure to do so precludes the
applicant from establishing his or her eligibility
to receive direct payment. An applicant who
establishes eligibility to receive direct payment
will be required to maintain insurance
Form SSA-1691

coverage in order to continue to receive direct
payment of fees from SSA.
Background Check
A background check is required of each
applicant to ensure his or her fitness to
practice before SSA. SSA rejects 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;

•

has failed to provide the required
documentation enabling SSA to
perform the criminal background
investigation;

•

has substantially misrepresented the
facts in submitting his or her application;

•

fails to pass an SSA administrative
records check (check of SSN, etc.).

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 will consist of 40 to 50
multiple-choice questions. Examination details
are as follows:
•

The examination instrument is written in
the English language only;

•

The examination will be given only once,
on a weekday, in conjunction 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);

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•

The examination will be based upon
situations that arise from the subject
areas contained in the reference
materials.

•

Applicants will not be permitted to
remove the examination instrument or
reference materials from the
examination center.

Open-book reference materials provided by
SSA are listed below. Applicants will not be
permitted to bring any other items (including
reference materials) to the examination center.
•
•

One copy of the 20 C.F.R., Chapter III
(Parts 400- 499), and
One copy of the Compilation of
Social Security Laws, Volume 1.

Applicants who fail to achieve a passing score
may re-apply during a subsequent application
period; however, they will be required to pay
the application fee again.
Continuing Education Courses (CE)
Applicants who become eligible non-attorney
representatives must complete courses to
meet the continuing education requirement.
The courses must enhance eligible nonattorney representatives’ professional
knowledge in matters such as those related to
entitlement to benefits, ethics, listing of
impairments, and other disability topics under

Form SSA-1691

titles II and XVI of the Act. We will prescribe
the course(s) and notify eligible non-attorney
representatives of when to complete and how
to certify that they have completed the
course(s).
Instructions for Completing this Form
• Please type or print legibly using only a
BLUE or BLACK ink pen.
•

Completely fill out all sections of this
form. Use "None" or "N/A" where
applicable.

•

Include an area code with all telephone
numbers.

•

Include a zip code with all addresses.

•

List your full middle name. If you do
not have a middle name, please indicate
this by showing "NMN" for a middle
name.

•

Line out and initial any changes you
make to your application.

•

If you require additional space, please
use Section D. Please indicate the
section and question number you are
responding to before you record the
additional information.

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OMB No. 0960-0699
Please read the instructions on pages 1 through 3 of this application for eligibility requirement.
SECTION A
First Name:

Background Information – Applicant’s Identifying Information
Full Middle Name:
Last Name:

Suffix:

Other Name(s) Used:

Reason(s) for other name(s) used:

SSN:

Date of Birth (mm/dd/yyyy):

Citizenship Status:
---- U.S. Citizen
SECTION A
Address:

---- Naturalized Citizen

---- Alien Authorized to work in the U.S.

Background Information – Applicant’s Contact Information
Home Phone:

Address (Line 2):

City:

---- Other If other, please specify:

Mobile Phone:

State:

Zip Code:

Work Phone:

E-mail Address:

SECTION A

Background Information – Additional Information

1. Are you a licensed or practicing attorney?
OR
Are you an attorney who has been disbarred or suspended from practicing in any
state?

---- Yes

---- No

2a. Do you have a bachelor’s degree from an accredited institution of higher
education? (If Yes, go to question 3. If No, please answer question 2b.)

---- Yes

---- No

2b. Do you have equivalent qualifications? (Only respond if you answered
No to question 2a.)

---- Yes

---- No

If yes to either of these questions, stop. Do not submit this application. Licensed or
practicing attorney are not required to take the examination in order to receive direct
pay. Disbarred or suspended attorneys are not eligible to take the examination.

SECTION A
Form SSA-1691

Background Information – Additional Information (continued)
Page 4

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

---- No

Name of Program or Agency:
If Yes, please provide the following information:
Address of Program or Agency:
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?
If Yes, please provide the following information:

Date of Reinstatement (if
applicable):
---- Yes

---- No

Name of Program or Agency:
Address of Program or Agency:
Details of Investigation:

Details of Investigation:

Status of Investigation:

5. Have you been determined to have fraudulently used or misused any Social Security
benefits?

---- Yes

---- No

6. Have you had a judgment or lien assessed against you by a civil court for
malpractice and/or fraud?

---- Yes

---- No

7. Have you ever had a felony conviction?

---- Yes

---- No

8. Have you been determined to have violated any Social Security program rules (e.g.,
rules regarding the disclosure of evidence or representative payee rules)?

---- Yes

---- No

9. Have you applied for the Social Security Administration Non-Attorney Representative
Examination before?

---- Yes

---- No

Date of Previous Application(s):
If yes, please provide the following information:
Disposition of Previous Application:
Any Changes to Report Since Previous Application:

SECTION B
Form SSA-1691

Education/Equivalent Qualifications – College/University Attended
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Please provide information on the accredited College or University from which you received your bachelor’s degree or
higher. Once you pass the examination, you must provide proof of your highest degree in the form of an official transcript
showing the stamp or raised seal, or otherwise establishing that it is an official copy.
Name of College/University:
City:
State:
Attended From (mm/yyyy):

Attended To (mm/yyyy):

Degree Granted?

---- Yes

---- No

---- Bachelor’s Degree
Indicate degree granted:
---- Doctorate Degree
---- Graduate Degree
SECTION B
Education/Equivalent Qualifications – High School Diploma or GED
If you do not have a bachelor’s degree or higher from an accredited College or University, you must provide
information regarding your High School Diploma or GED. Once you pass the examination, you must provide proof in the
form of a copy of your high school transcripts, diploma, or GED certificate (or other equivalent documentation).
High School or GED Certificate:
Date Diploma or Certificate Awarded (mm/yyyy):
City:

State:

SECTION B
Education/Equivalent Qualifications – Relevant 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 about relevant professional experience. You must provide four years of relevant training or work experience
through which you have 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 work
experience involving claims for benefits under title II or title XVI of the Act shall also be defined as relevant professional
experience. In the Position Description field, you must add enough detail for SSA to determine if the cited experience
constitutes relevant professional experience. Once you pass the examination, you must provide proof (e.g., IRS Form W-2,
wage and tax Statement (s)) of your professional experience.
1. This experience is:
---- SSA Related Professional Experience
---- Other Professional Experience
Position/Title:
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

Position Description:

Name of Employer:
Address:
City:

State:

Name of Supervisor:

Employer Phone:

Zip Code:

If you require additional space, please use Section D
Form SSA-1691

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SECTION C
Examination Information
The exam will be administered at designated locations across the country. The exam will be held on the same date at each
location. SSA may cancel any site if enrollment does not meet minimum standards. In that event, applicants will be
notified at least 20 days prior to the test date in order make appropriate travel arrangements to an alternate test site. See
the Attorneys and Appointed Representatives Website at http://www.ssa.gov/representation/ for a list of exam locations.
Applicants will be asked to select a first and second choice for their examination location (for use if they pass a criminal
background check 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 correct 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. Detailed information concerning the specific location of the examination site will be mailed to those
applicants determined eligible to sit for the examination.
First Choice Location
City:
State:
Second Choice Location

City:

State:

SECTION C
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 along with your application to the
address indicated on the Attorneys and Appointed Representatives Website at http://www.ssa.gov/representation/.

Please initial indicating that you understand that you must provide written documentation to support
your request for special accommodations along with your application.

Form SSA-1691

Initials:

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SECTION D

Form SSA-1691

Additional Information

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Privacy Act Statement
Collection and Use of Personal Information
Section 3 of the Social Security Disability Applicants’ Access to Professional Representation Act of 2010, authorizes us to
collect this information. We will use the information you provide to further document your application and permit a
determination about your eligibility to receive direct payment of fees (from a claimant’s past-due benefits) for your
representation services.
The information you furnish on this form is voluntary. However, failure to provide the requested information could result in
a determination that you are ineligible to receive direct payment of fees.
We rarely use the information you supply for any purpose other than for determining eligibility to receive direct payment of
fees. 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 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);
2. To employers of claimants’ representatives, to assist in collecting debts owed by representatives who
received an excess or erroneous representational fee payment and owe a delinquent debt, or as necessary
for us to carry out the requirements for fee reporting to appointed representatives; and

3. To facilitate 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 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 Systems of Records Notice 60-0325 (Appointed
Representative File). The Notice, additional information about this form, and information regarding our systems and
programs, are available on-line at www.socialsecurity.gov or at your local Social Security office.
Please initial indicating that you have read and understand the Privacy Act Statement.
Initials:

Form SSA-1691

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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 Budget control number. We
estimate that it will take 30 - 45 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
Please initial indicating that you have read and understand the Paperwork Reduction Act
Initials:
Statement.
Substantial Misrepresentation or Material Discrepancy Statement
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 to sit for the examination or to receive direct payment of fees.
Please initial indicating that you have read and understand the Substantial Misrepresentation or Initials:
Material Discrepancy statement.
Application Fee Statement
The application fee is non-refundable. See the Attorneys and Appointed Representatives Website for additional
information.
Please initial indicating that you have read and understand the statement regarding the applicable Initials:
fee.
Statement of Understanding
I understand that I must sign the application in ink and submit the application fee and complete application package to
the address indicated on the Attorneys and Appointed Representatives Website at
http://www.ssa.gov/representation/. 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.
This application package must be postmarked or receipt-dated (if sent by private express service) by midnight
E.D.T. of the last day of the application period. I further understand that the application fee is generally nonrefundable. SSA will not process my application until the completed application package is received. If this
requirement is not met as of midnight E.D.T. of the last day of the application period, SSA will process my
application as a denial. See the Attorneys and Appointed Representatives Website at
http://www.ssa.gov/representation/ for information about the application period.
Please initial indicating that you have read and understand the Statement of Understanding
Initials:
statement:
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)
Date:

Form SSA-1691

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OMB o. 0960-0699
Social Security Administration
PLEASE READ CAREFULLY
APPLICANT AUTHORIZATION FOR RELEASE OF INFORMATION
I authorize SSA to conduct a criminal background check in which SSA 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 SSA any criminal history information pertaining to me
that may be in the agency’s files. I authorize SSA, and any of its agents, to disclose orally and in writing the results
of this criminal background check to the business entity that manages the information for managing direct payment
eligibility for non-attorney representatives.
I understand that the results of the criminal background check may be used by SSA to determine my eligibility to sit
for the examination and receive direct payment, 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 sit for the examination or to receive direct payment, I understand that SSA
will provide me a copy of the report on the criminal background check submitted by SSA 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:
Middle Name:

Social Security Number:

Date of Birth:

Place of Birth:

Sex:

Race (Optional):

Current Address:

Please list all of the addresses you have lived at in the last 5 years
From: (mm/dd/yyyy) – Present:
City/State/Zip Code:

Previous Address:

City/State/Zip Code:

From: (mm/dd/yyyy) – To: (mm/dd/yyyy)

Previous Address:

City/State/Zip Code:

From: (mm/dd/yyyy) – To: (mm/dd/yyyy)

Previous Address:

City/State/Zip Code:

From: (mm/dd/yyyy) – To: (mm/dd/yyyy)

Applicant’s Signature

Form SSA-1691

Date:

Daytime Phone:

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