Form SSA-1696-SUP1 Claimant's Revocation of the Appointment of a Representa

Form SSA-1696-SUP1 (XX-20XX)
Social Security Administration

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OMB No. 0960-0527

Instructions for Completing Form SSA-1696-SUP1
Keep a copy of this form for your records
In this document, “you” means the claimant, beneficiary, auxiliary or spouse. “Us” and “SSA” means the Social Security
Administration.
General Information About This Form
This form is optional. Complete it only when applicable, either in-person at your local field office, mail it, or fax it to us. You should
also tell your representative.
Revocation of a Representative’s Appointment
You may use this form to end (revoke) an appointed representative’s authority at any time during the processing of your claim.
You must sign and date your revocation and file it with us either in-person at your local field office, mail it, or fax it to us. You
should also tell your representative. Once you revoke the appointment, we will no longer deal with the named representative. If
you have no other representatives, you may continue with your claim unrepresented or appoint a new representative. If the
individual you revoke is your principal representative, you must give the name of your new principal representative. The revocation
will take effect on the date we receive the signed document.
Privacy Act Statement - Collection and Use of Personal Information

DRAFT

Sections 206 and 1631(d) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this
information is voluntary. However, failing to provide all or part of the information may prevent us from ending the appointment of a
representative authorized to act on your behalf.
We will use the information to revoke the appointment of your representative. We may also share your information for the following
purposes, called routine uses:
• To a congressional office in response to an inquiry from that office made on behalf of, and at the request of, the subject
of the record or a third party acting on the subject’s behalf;
• To a Federal, State, and local law enforcement agencies and private security contractors, as appropriate,
information necessary:
(a) to enable them to protect the safety of Social Security Administration (SSA) employees and customers, the
security of the SSA workplace, and the operation of SSA facilities; or
(b) to assist investigations or prosecutions with respect to activities that affect such safety and security or
activities that disrupt the operation of SSA facilities; and
• To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration
of its programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089, entitled Claims
Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784; 60-0320, entitled Electronic Disability
Claim File, as published in the FR on December 22, 2003, at 68 FR 71210; and 60-0325, entitled Appointed Representative File,
as published in the FR on October 8, 2009, at 74 FR 51940. Additional information and a full listing of all our SORNs are available
on our website at www.ssa.gov/privacy.
Paperwork Reduction Act Statement
This information collection meets the clearance 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 30 minutes to read the instructions, gather the facts, and answer
the questions. You may send us your comments on our estimated completion time 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
• 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq.

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Form SSA-1696-SUP1 (XX-20XX)

Claimant's Revocation of the Appointment of a Representative
You, the claimant, can stop your representative from working on your behalf. Complete, sign, and date the section below and
submit it to one of our offices. Use a separate form for each appointment you want to revoke. Do not forget to enter your Social
Security Number, and if you know it, your representative’s identification number (Rep ID).

Claimant's Information
Claimant's Social Security Number

Claimant's First Name

Initial Last Name

Claimant's Address

City

DRAFT

State

ZIP/Postal Code

Representative's Information
Representative's Rep ID

I revoke the appointment of a representative that I previously appointed. I understand that this representative may be entitled to a
fee. The representative is:
Name

This was my principal representative. I have appointed multiple representatives and I now name as my new
principal representative:
Name

Representative's Address

City

Claimant's Signature

State

ZIP/Postal Code

Date