Appointment of Representative

Forms and Documents

Document Name	Status
Form SSA-1696 Appointment of Representative - SSA-1696 Form and Instruction	Modified
Form SSA-1696-SUP2 Representative's Withdrawal of Acceptance of an Appointment - SSA-1696-SUP2 Form and Instruction	Unchanged
Form SSA-1696-SUP1 Claimant's Revocation of the Appointment of a Representative - SSA-1696-SUP1 Form and Instruction	Unchanged
Justification for Non-Substantive Changes - 0527 (final).docx Justification for No Material/Nonsubstantive Change	2021-09-29
Supporting Statement - 0527.docx Supporting Statement A	2019-06-03

IC Document Collections

IC ID	Document Title	Status
9438	Appointment of Representative - SSA-1696 Form and Instruction	Modified
235152	Representative's Withdrawal of Acceptance of an Appointment - SSA-1696-SUP2 Form and Instruction	Unchanged
235151	Claimant's Revocation of the Appointment of a Representative - SSA-1696-SUP1 Form and Instruction	Unchanged

ICR Details

OMB Control No: 0960-0527	ICR Reference No: 202109-0960-006
Status: Received in OIRA	Previous ICR Reference No: 202103-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Appointment of Representative
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/29/2021

	Requested	Previously Approved
Expiration Date	06/30/2022	06/30/2022
Responses	1,054,000	1,054,000
Time Burden (Hours)	181,167	181,167
Cost Burden (Dollars)	0	0

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Abstract: Recipients use Form SSA-1696 to appoint a representative to handle their claim before SSA. Recipients’ representatives use the Form SSA-1696 to indicate whether they will charge a fee, and, if so, specify their eligibility for direct fee payment. The representatives also use Form SSA 1696 to indicate their disbarment or suspension from a court or bar in which they previously admitted to practice, or their disqualification from participating in or appearing before a Federal program or agency. SSA recognizes the recipient’s representative as the individual named in a notice of appointment (or written statement), which the recipient signed and filed at an SSA office. The SSA 1696 (or written statement) documents the appointment of a representative. We also use this form to collect the business affiliation and EIN of the representatives. Our regulations also require that if the representative is a non attorney, they must sign the form or equivalent written statement. In addition, respondents use the SSA 1696-SUP1 to revoke their appointment of a representative, and representatives use the SSA 1696-SUP2 to withdraw their acceptance of the appointment. SSA uses this information to document the revocation and withdrawal of a representative. Respondents are applicants for, or recipients of, Social Security disability benefits (SSDI); SSI payments; or anyone pursuing a benefit or invoking a right under SSA programs, who are notifying SSA they have appointed a person to represent them in their dealings with SSA, and their non attorney representatives who need to sign the form. This is an IT Mod non-substantive Change Request to make minor revisions to the current Adobe Sign submittable PDF version of the SSA-1696.

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Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
   US Code: 42 USC 406 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 31987	07/10/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 4597	02/15/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Appointment of Representative - SSA-1696	SSA-1696	Appointment of Representative
Claimant's Revocation of the Appointment of a Representative - SSA-1696-SUP1	SSA-1696-SUP1	Claimant's Revocation of the Appointment of a Representative
Representative's Withdrawal of Acceptance of an Appointment - SSA-1696-SUP2	SSA-1696-SUP2	Representative's Withdrawal of Acceptance of an Appointment

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,054,000	1,054,000	0	0	0	0
Annual Time Burden (Hours)	181,167	181,167	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $36,900

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Yes

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Yes

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/29/2021

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