Current e1696 Screens

@ Social Security
Complete the Notice of Appointment (Form SSA-1696)
Instructions for Representatives

This service allows you and the individual you agree to represent (i.e., the claimant) to complete your respective sections of the notice of
appointrnent (Form SSA-1696) online, sign the form electronically, and submit it to us electronically. Before you begin, you will need the
following information:
•
•
•
•

Your valid email address.
The claimant's valid email address.
Your current mailing address and phone number.
If you are registered, you will also need your Representative Identification (RepID) (This is the number you were assigned when you
registered with us).

IMPORTA!W: Submission of this form is a two-step process for each signer. We will not receive or process the form until both parties have
completed their steps.
Step One. You, the Representative, must complete your designated sections of the form, sign the fonn electronically, and submit it to Adobe
Sign.

Before beginning the fonn, you will first enter your and the claimant's email addresses into the application online.
You will also create a password that will be required for you and the claimant to access the form. You should provide the password to
claimant by phone, in person, or SMS text message (standard message and data rates may apply). If you are unable to contact the
claimant by phone, in person, or by text, then you may send the password via a separate email message.
You will receive an email from adobesign@adobesign.com containing a link and instructions on how to access the fonn.
NOTE: After you sign the fon11, the claimant will also receive an email from adobesign@adobesign.com containing a link and
instn1ctions on how to complete his or her portions of the fonn and subnut it to SSA.

The fonn will be available to you and the clairnant for 5 calendar days after you initiate the process online (i.e., when you enter your
and the claimant's email addresses in order to receive a link to co111plete the forn1). You should infonn the claimant about the
importance of taking action in response to this email upon receipt of the email. If you and the claimant do not complete, sign, and
submit the fonn within five (5) calendar days, you will need to start a new form.
Step Two. Upon receipt of email notification that the first step has been completed by you, the claimant accesses and reviews the partially
completed form, completes their designated sections, signs the fonn electronically, and subnuts the fonn to us.

After successful submission of the fonn, adobesign@adobesign.com will send an email to you and the claimant with a link to the
submitted fonn. This will allow you to save a copy for your records.
We will notify you and the clairnant by mail when your form has been processed.
PLEASE NOTE:

• This website is most compatible with the following browsers: Microsoft. Edge and Google Chrome.
• After 60 mirmtes of inactivity, the system will end your session, the fonn will delete the infonnation you entered during the session, and you
will have to repeat the first step again.
• If you (or the claimant) do not see an email notification within a few minutes of subnussion, check your junk folder. If you do not receive an
email, you will need to submit a new fonn. We recorru11end that you verify the accuracy of your and your claimants' email address.
• A daily email rerninder will be sent to you and the claimant until the fonn has been subnutted or until the time expires.
• If you or the claimant lose the password, we do not have the ability to reset the password. You will have to restart the process.

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 appointing a representative to act on your behalf.
We will use the information to verify the appointment of your representative and his or her acceptance of the appointment. We may also
share your info1111ation 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 ot~ the subject of the record or
a third party acting on the subject's behalf;
• To 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 disrnpt the
operation of SSA facilities; and
• To contractors and other Federal agencies, as necessa1y, for the purpose of assisting SSA in the efficient administration of its programs.
In addition, we may share this infom1ation 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 October 31, 2019, at 84 FR 58422; 60-0320, entitled Electronic Disability Claim File, as published
in the FR on June 4, 2020, at 85 FR 34477; 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, is available on our website at http://wvvw.ssa.gov/privacy.

~ * I understand and agree to the above statement

Start Application

® Social Security
Appointment of Representative
Representatives: This form will expire after 5 calendar days if the Claimant does not sign and submit the form. If the Claimant
does not submit the form within 5 days, you will need to send a new form to the Claimant. You wi ll need to provide the claimant
with the password that you have created.
Representative's Email Address
Enter Representative's Email Address

Confirm Representative's Email Add ress
Confirm Representative's Email Address

Claimant's Email Address
Enter Claimant's Email Address

Confirm Claimant's Email Address

I

Confirm Claimant's Email Address

Document Name
Appointment of Representative

Password Required
Password must contai n at least 8 characters, 1 uppercase , 1 lowercase, and 1 number.
Password

I

Confirm Password

D

Show Password

~

Completion Deadline

01/30/2021

Submit

® Social Security
Appointment of Representative
To complete the online form, open the email from adobesign@adobesign.com and click on the
"Review & Sign" button.

Fri 1/29/2021 10:09 AM

Social Security Administration
[EXTERNAL] Social Security Adm inistrat ion Has Sent You Appointment of Representative to Sign
To Representative 's Email

Retention Po licy

0

Delete_7_Year_Default (J years)

Expires

1/28/2028

If t here are problems wit h how this message is displayed, click here to view it in a web browser.

Social Security Adm inistration requests your signature
Appointment of Representative
Form Expires On February 3, 2021

Review and sign

THIS LINK EXPIRES IN 5 CALENDAR DAYS.
You have a document to review and sign. You can access the document using the link above. For additional security, the
representative has set an open password for this document. If you are not the representative, you will need to contact the
representative to get the password in order to review this document. If any of the information in the document is incorrect or
if you disag ree wit h any of the information, the representative shou ld restart the process.
This link is persona lized for you and for security purposes, we recommend you do NOT forward/share this ema il or link with
others. If you DO forward/share this email or link with others, you accept the risk that by sharing your persona l information,
the person assisting you may misuse your personal information. If you have any questions about this email or feel that you
received this in error, please contact SSA at 1-800-772-1 21 3 (TTY 1-800-325-0778) between 8:00 am - 7:00 pm, Monday
through Friday.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit https://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800269-0271 (TTY 1-866-501-2101).

SOCIAL SECURITY ADMINISTRATION

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you agree that this agreem ent may be signed using electronic or handwritten signatures.

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Appointment of Representative

Form SSA-1696 (12-2020) UF
Discontinue Prior Editions
Social Security Administration

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Page 1 of6
0MB No. 0960-0527

Instructions for Completing Form SSA-1696
Follow the link we send you after you s ubmit the f orm to print and/or save a copy of this f orm for y our records
YOU DO NOT HAVE TO SIGN THIS FORM - Use and si~n this form to appoint an individual to act on your behalf in your claim
pending with us. If you do not agree with any information on this foon, do not sign it Refusing to sig-i the form will not affect how we
process and decide your claim.
You may only file this electronic version of Form SSA-1696 if you have a claim or other issue pending with us. In this document,
•you" means the claimant, beneficiary, auxiliary, or spouse. · us· and · ssA· means the Social Security Actninistration.

If you suspect Social Security Fraud - If you suspect Social Security fraud, please visit http:1/oig.ssa.gov/r or call the Inspector
Generars Fraud Hotline at 1-800-269-0271

TY 1-866-501-2101 .

General Information About This Form
• You may appoint a qualified representative of your choice to represent you on any claim or asserted right under any of our
programs. For more information on who can qualify to be an appointed representative, when your representative's
appointment begins or ends, payment of fees to appointed representative{s), and other helpful information, you can visit our
website at www.ssa.gov/representation, or call us, toll-free, at 1-800-772-1213. To find othe< helpful information or the
address and telephone number for your local Social Security field office, you can visit www ssa goy[Jocator
• You may use this electronic version of Form SSA-1696 to appoint a representative. However, we do not require you to use
this electronic version; you can still use the paper version to tell us about your appointment Afte< you read, complete, and
electronically sign the form, you must crtck · click to Sign" to send us this form, or your appointment will not reach us. If we
successfully process your appointment, we will send you a notice to tell you. You do not need to submit a paper form if you
submit this electronic version.
• You may also choose to be unrepresented. We handle your case in the same manne< whether you are represented or
unrepresented. You do not need to appoint someone who simply helps you through the process. For example, you do not need to
appoint someone who helps you call us, reads to you from documents, or interprets for you if you speak another language. You
only need to appoint someone if he or she will be acting or appearing on your behalf, or will be making decisions about your case
for you. If you choose to be unrepresented (or do not want to appoint the individual identified on this electronic form), do not
complete or submit this form.
• You and your representative(s) must give us accurate information as quickly as possible. Providing misleading or false evidence
on this form or your application, or withholding or delaying giving us evidence, could lead to possible criminal charges or
administrative sanctions against you or your representative.
Appointing a Representative
Before completing your sections of this electronic form, please review the sections that you can view that were completed by the
representative. If you agree with all of the information already entered, complete the highlighted sections, electronically sign and date
the form in Section 8, and submit it to us by clicking "Click to Sign: After you submit the form successfully, you will receive an email
from adobesign@adobesign.com with a link that will take you to a copy of the completed form that you can keep for your records. If
you are appointing multiple representatives, you must use a separate form for each representative.
Section 1 - Claimant's Information and Number Ho lder's lnfonnation
Your representative will complete your name. You must complete all of the other information, including your Social Security number.
If you are filing your action on someone else's Social Security record, this person is the "number holder" and we need his or her
information to process your daim.
Section 2 - Authorization for Disclosure
By selecting the disclosure box, you are authorizing us to give information to your representati ve's staff, partners, associates,
and other individuals who work for or with your representative (such as contractors and copying services) about you and your pending
case. We will check the credentials of the individuals requesting information on behalf of your representative for authentication
purposes.
Section 3 - Principal Representative
If you appoint or have appointed multiple representatives, you must name your principal representative who will be our main point of
contact We will send copies of your notices to this individual and communicate directly with him or her.
Section 4 - Representative's Information
Your representative must complete this section and submit this form by clicking "Click to Sign." It is important that he or she fill in all
the boxes in this section, including the Representative Identification Number (Rep ID) if he or she has one.

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Form SSA-1696 (12-2020) UF

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Sectio n 5 - Representative's Status, Affiliatio ns, and Certificatio ns
Your representative must complete this section to let us know his or her status as a professional. If your representative is seeking
a fee and is working for an employer, entity, or firm, he or she must also complete the affiliation section and give us the
Employer's Identification Number (EIN). We will provide both your representative and the employer, entity, or firm information of
the reported income. For more information about your representative's reported income and employer registration, visit our
website at www.ssa.gov/representation. Your representative must certify the accuracy of all statements in this section.
Section 6 - Claim Type
The representative completes this section. Your representative will check the boxes for the types of daims you will be appointing
them to represent you.
Section 7 - Fee Arrangement
Generally, to charge a fee for services, your representative must get our approval. Your representative may waive the right to
charge you a fee or tell us that a third party entity (business, government agency, or organization) will pay the fee. In these
situations, the third party must pay out of its own funds the fee and any expenses, and you and any auxiliary beneficiaries (e.g.,
children or spouse) must be free of responsibility to pay any fees or expenses. If your representative is eligible for direct payment,
he or she also may waive the right to direct payment.
Section 8 - Signatures
You must electronically sign and date this section and send the completed form to us by clicking the "Click to Sign· button.
Remember, by signing this form you are appointing the named individual as your representative and authorizing us to disclose to
him or her any information relevant to your claim(s) as if he or she were you. If you select the box in section 2, we may also disclose
the same information to your appointed representative's associates .

Privacy Act Statement - Collection and Use of Personal Info rmation
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 appointing a representative to act on your
behalf.
We will use the information to verify the appointment of your representative and his or her acceptance of the appointment We may
also share your information for the following purposes, called routine uses:
• To a congressional office in response to an inquiry from that offi ce 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 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 A dministration (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 saf ety and security or acti vities
that disrupt the operation of SSA f acilities; andl
• To contractors and other Federal agencies, as necessary, f or the purpose of assisting SSA in the effi cient 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 edigibility 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 October 31 , 2019, at 84 FR 58422; 60-0320, entitled Electronic
Disability Claim File, as published in the FR on June 4, 2020, at 85 FR 34477; 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, is
available on our website at www.ssa.gov/privacy.
Paperwork Reductio n Act Statement
This information collection meets the clearance requiremen ts 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
• 18 U .S.C. §§ 203, 205, and 207; 42 U.S.C. §§ 406, 1320a-6, 1363(d )(2) and 1631 ;
• 26 U .S.C. §§ 6041 and 6045(f) and 20 CFR §§ 404 .1700 et. seq. and 416.1500 et seq.

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Fonn SSA-1696-APP (02-2021) UF
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Security Administration

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Page 3 of 6
0MB No. 0960-0527

Claimant's Social Security Number

I

Appointed Representative's Rep ID

I

1123456789A

•

Claimant's Appointment of a Representative
I

Section 1 - Claimant's Information

First Name

I

Initi al Last Name

Test

Claimant

EE

Maili ng Address

City

State

Phone Number

I

Z IP/Postal Code Count ry - if o utside t he U. S.

Alternate Phone Number (Opt io nal)

I

Number Holder's Information (Complete when applicable)

My claim is based on another person's work or earnings (e.g., spouse or parent). This person's information is different from mine.
Number Holder's Social S ec urity Number

First Name

I

IInitial ' Last Name
Section 2 - Disclosure (Claimant Only)

I

D By selecting this box, I, the claimant listed in Section 1, whose signature appears in Section 8, authorize SSA to release
information in relation to my pending claim(s) or asserted right(s) to designated associates who perform administrative duties
(e.g ., clerks. assistants). partners, or parties under contractual arrangements for or with my representative. (The appointed
representative's parlners. associates, delegates and designees must be prepared to provide information in order to be
authenticated.)

I

Section 3 - Principal Representative (Claimant only- Complete when applicable)

I

I have appointed before, or appoint now, more than one representative. I ask SSA to make contacts or send notices to this
individual. My principal representative is:
Name

I

Language English: US

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Page 4 of 6

Fonn S SA-1696-APP (02-2021) UF
Claimant's Social Security Number

I

Appointed Representative's Rep ID

I

I

I123456789A

•

Section 4 - Representative's Information

Representatives who are eligible and seek direct payment of their fee must register and receive a Rep ID before the appointment.
For more infonnation about registration visit us on-line at www socjalsecyrity goy/ar contact us at 1-800-772-1213
(TTY 1-800-325-0778), or visit your local Social Security office.
First Name

Test

Mailing Address

Fake Address

Citv

State

Fake City

Maryland

Phone Number

12345

Alt ernate Phone Number (O ptional)

1112223333

111 -222-3333

I

ZIPfPostal Code Countrv - if o utside the U.S.

Section 5 - Representative's Status, Affiliations, and Certifications

I

Representative's Status Part A - Type of Representative (Representatives have a d uty to keep their i nfor mation current)
@ I am an attorney (SSA law states that an attorney is someone in good standing who has the right to practice law before a
court of a State, Territory, District, or island possession of the United States, or before the Supreme Court or a lower
Federal court of the United States.)

0

I am a non-attorney eligible for direct payment (SSA law requires that non-attorneys meet certain criteria to qualify for direct
payment Refer to our webs le at www .ssa.govlrepresentation for criteria).

0

I am a non-attorney not eligible for direct payment.

0

I work for a non-profit organization (e.g. a law clinic or state legal aid)

Representative's Status Part B - Disqualification
I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice law.
@ Yes

O

No

I am now or have previously been disqualif ied from participating in or appearing before a Federal program or agency.
@ Yes

I

Language English: US

O

No

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Page 5 of 6

Form SSA-1696-APP (02-2021) UF
Appointed Representative's Rep ID

Claimant's Social Security Number

I 123456789A

•

Section 5 - Continued
Affiliation Information
If you are representing the claimant(s) as a partner or employee of a business entity, firm or other organization you may provide
your Employer Identification Number (EIN) here, if one exists for tiax purposes. This number is not your Social Security Number
(SSN). This is your employer's tax identification number. (Oo not complete this section if you do not qualify for direct payment. )
EIN

1123456789

Or ganizatio n's Name (Enter the full name of the business, entity, firm or organization with which you want to be affiliated YAi ile
representing this claim)

Test Organization
Representative's Business Address (if different than mailing ad'.d ress)

Test Address
Citv

Test City

State

ZIP/Postal Code

Maryland

12345

Country - if o utsid e the U.S.

Representative's Certifications
I accept this appointment and certify the following:
• I understand and agree that I will comply with SSA's laws and rules on the representation of parties, including the Rules of
Conduct and Standards of Responsibility for Representatives; I will not charge, collect,

or retain a fee for representational

services that SSA has not approved or that is more than SSA approved unless a regulatory exclusion applies.
• I understand that if I fail to comply with any of SSA's laws and rules I may be suspended or disqualified as a representative
before SSA.
• I will not disclose any information to any unauthorized party without the claimant's specific written consent.
• I am not currently suspended or prohibited, for any reason, from practicing before the Social Security Administration.
• I am not disqualified from representing the claimant as a current or fonner officer or employee of the United States.
• I accept appointment as the representative for the claimant named in Section 2 of this form in connection with the claims and
asserted rights described in Section 6 of this form.
• I agree that a copy of this signed form SSA-1696 w ill have the same force and effect as the original.
• I declare under penalty of perjury that I have examined all of the information on this fonn and on all accompanying statements or
forms, including any information, attestations and certifications provided to SSA in registration, and that they are all currently true
and correct to the best of my knowledge.

If I intend to seek direct payment of the authorized fee on this claim • I have registered for and obtained a Rep ID, and my registration information is up-t
[EXTERNAL] Social Security Adm inistrat ion Has Sent You Appointment of Representative to Sign
To Claimant's Email Address

Retention Po licy

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Expires

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If t here are problems wit h how this message is displayed, click here to view it in a web browser.

Social Security Adm inistration requests your signature
Appointment of Representative
Form Expires On February 3, 2021

Review and sign

THIS LINK EXPIRES IN 5 CALENDAR DAYS.
You have a document to review and sign. You can access the document using the link above. For additional security, the
representative has set an open password for this document. If you are not the representative, you will need to contact the
representative to get the password in order to review this document. If any of the information in the document is incorrect or
if you disag ree wit h any of the information, the representative shou ld restart the process.
This link is persona lized for you and for security purposes, we recommend you do NOT forward/share this ema il or link with
others. If you DO forward/share this email or link with others, you accept the risk that by sharing your persona l information,
the person assisting you may misuse your personal information. If you have any questions about this email or feel that you
received this in error, please contact SSA at 1-800-772-1 21 3 (TTY 1-800-325-0778) between 8:00 am - 7:00 pm, Monday
through Friday.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit https://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800269-0271 (TTY 1-866-501-2101).

SOCIAL SECURITY ADMINISTRATION

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you agree that this agreem ent may be signed using electronic or handwritten signatures.

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Form SSA-1696-APP (02-2021 ) UF
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0MB No. 0960-0527

Instructions for Completing Form SSA-1696
Follow t he link we send you after you submit the form to print and/or save a copy of this form f or y o ur records
YOU DO NOT HAVE TO SIGN THIS FORM - Use and sign this form to appoint an individual to act on your behalf in your claim
pending with us. If you do not agree with any information on this form, do not sign il Refusing to si!Jl the form will not affect how we
process and decide your claim.
You may only file this electronic version of Form SSA-1696 if you have a claim or other issue pending with us. In this document.
· you" means the claimant, beneficiary, auxiliary, or spouse. · us· and · ssA" means the Social Security Aooiinistration.

If y ou suspect So cial Security Fraud - If you suspect Social Security fraud, please visit httpJ/oig.ssa.gov/r or caD the Inspector
Generars Fraud Hotline at 1-800-269-0271 TY 1-866-501-2101 .
Gener al Informatio n Ab out This Form
• You may appoint a qualified representative of your choice to represent you on any claim or asserted right under any of our
programs. For more information on who can qualify to be an appointed representative, when your representative's
appointment begins or ends, payment of fees to appointed representative(s). and other helpful information, you can visit our
website at www.ssa.gov/representation, or call us, toll-free, at 1-800-772-1213. To find other helpful information or the
address and telephone number for your local Social Security field office, you can visit www ssa goy/)ocator
• You may use this electronic version of Form SSA-1696 to appoint a representative. However, we do not require you to use
this electronic version; you can still use the paper version to tell us about your appointment After you read, complete, and
electronically sign the form, you must click · click to Sign" to send us this form, or your appointment will not reach us. If we
successfully process your appointment, we will send you a notice to tell you. You do not need to submit a paper form if you
submit this electronic version.
• You may also choose to be unrepresented. We handle your case in the same manner whether you are represented or
unrepresented. You do not need to appoint someone who simply helps you through the process. For example, you do not need to
appoint someone who helps you call us, reads to you from documents, or interprets for you if you speak another language. You
only need to appoint someone if he or she will be acting or appearing on your behalf, or will be making decisions about your case
for you. If you choose to be unrepresented (or do not want to appoint the individual identified on this electronic form), do not
complete or submit this form.
• You and your representative{s) must give us accurate information as quickly as possible. Providing misleading or false evidence
on this form or your application, or withholding or delaying giving us evidence, could lead to possible criminal charges or
administrative sanctions against you or your representative.
Appointing a Representative
Before completing your sections of this electronic form, please review the sections that you can view that were completed by the
representative. If you agree with all of the information already entered, complete the highlighted sections, electronically sign and date
the form in Section 8, and submit it to us by clicking "Click to S ign." After you submit the form successfully, you will receive an email
from adobesign@adobesign.com with a link that will take you to a copy of the completed form that you can keep for your records. If
you are appointing multiple representatives, you must use a separate form for each representative.
Section 1 - Claimant's Information and Number Holder's Informati on
Your representative will complete your name. You must complete all of the other information, including your Social Security number.
If you are filing your action on someone else's Social Security record, this person is the ·number holder" and we need his or her
information to process your claim.
Section 2 - Authorization for Disdosure
By selecting the disclosure box, you are authorizing us to give information to your representative's staff, partners, associates,
and other individuals who work for or with your representative (such as contractors and copying services) about you and your pending
case. We will check the credentials of the individuals requesting information on behalf of your representative for authentication
purposes.
Section 3 - Principal Representative
If you appoint or have appointed multiple representatives, you must name your principal representative who will be our main point of
contact We will send copies of your notices to this individual and communicate directly with him or her.

z

Section 4 - Representative's Information
Your representative must complete this section and submit this form by clicking "Click to Sign." It is important that he or she fill in all
the boxes in this section, including the Representative Identification Number (Rep ID) if he or s he has one.

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Form SSA-1696-APP (02-2021) UF

Section 5 - Representative's Status, Affiliations, and Certifications
Your representative must complete this section to let us know his or her status as a professional. If your representative is seeking
a fee and is working for an employer, entity, or firm, he or she must also complete the affiliation section and give us the
Employer's Identification Number (EIN). We will provide both your representative and the employer, entity, or firm information of
the reported income. For more information about your representative's reported income and employer registration, visit our
website at www.ssa.gov/representation. Your representative must certify the accuracy of all statements in this section.
Section 6 - Claim Type

The representative completes this section. Your representative will check the boxes for the types of daims you will be appointing
them to represent you.

Section 7 - Fee Arrangement
Generally, to charge a fee for services, your representative must get our approval. Your representative may waive the right to
charge you a fee or tell us that a third party entity (business, government agency, or organization) will pay the fee. In these
situations, the third party must pay out of its own funds the fee and any expenses, and you and any auxiliary beneficiaries (e.g.,
children or spouse) must be free of responsibility to pay any fees or expenses. If your representative is eligible for direct payment,
he or she also may waive the right to direct payment.
Section 8 - Signatures
You must electronically sign and date this section and send the completed form to us by clicking the "Click to Sign" button.
Remember, by signing this form you are appointing the named individual as your representative and authorizing us to disclose to
him or her any information relevant to your claim(s) as if he or she were you. If you select the box in section 2, we may also disclose
the same information to your appointed representative's associates.
Privacy Act Statem ent - Collection and Use of Personal Information
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 appointing a representative to act on your
behalf.
We will use the information to verify the appointment of your representative and his or her acceptance of the appoinbnenl 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 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 faci lities; 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 October 31, 2019, at 84 FR 58422; 60-0320, entitled Electronic
Disability Claim File, as published in the FR on June 4, 2020, at 85 FR 34477; 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, is
available on our website at www.ssa.gov/privacy.

Paperwork Reduction A ct 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.

z

References
• 18 U.S.C . §§ 203,205, and 207; 42 U.S.C. §§ 406, 1320a--6, 1383(d)(2) and 1631 ;
• 26 U.S.C. §§ 6041 and 6045(f) and 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq.

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Discontinue Prior Editions Social
Security Administration

Page 3 of6
0MB No. 0960-0527

Claimant's Social Security Number

I

a

Appointed Representative's Rep ID

111-22-3333

I

I

I123456789A

Claimant's Appointment of a Representative

I

Section 1 - Claimant's Information

First Name

Initial Last Name

Test

Claimant

Mamng Address

Test Address

(il
ZIP/Postal Code Countrv - if outside the U.S.

State

Citv

Test City

Maryland

Phone Number

12345

Alternate Phone Number (Optional)

111-222-3333

1112223333

I

Number Holder's Information (Complete when applicable)

I

My claim is based on another person's work or earnings (e.g., spouse or parent). This person's information is different from mine.
Number Holder 's Social Security Number

1999887777

I
1•••;a11Last Name

First Name

Test

Person

I

Section 2 - Disclosure (Claimant Only)

D

By selecting this box, I, the claimant fisted in Section 1, whose signature appears in Section 8, authorize SSA to release
information in relation to my pending claim(s) or asserted right(s) to designated associates who perform administrative duties
(e.g., clerks. assistants), partners, or parties under contractual arrangements for or with my representative. (The appointed
representative's partners, associates, delegates and designees must be prepared to provide information in order to be
authenticated.)

I

Section 3 - Principal Representative (Claimant only - Complete when applicable)

I have appointed before, or appoint now, more than one representative. I ask SSA to make contacts or send notices to this
individual. My principal representative is:
Next

"-

Name

Test Name Here

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Form SSA-1696-APP (02-2021) UF

ID

X

Appointed Representative's Rep ID

Claimant's Social Security Number

I

a

111-22-3333

I123456789A

Section 4 - Representative's Information
Representatives who are eligible and seek direct payment of their fee must register and receive a Rep ID before the appointment
For more information about registration visit us on-line at www scx;ialsecyrjty goyfar, contact us at 1-800-772- 1213
(TTY 1-800-325-0TT8), or visit your local Social Security office.

First Name

Initial Last Name

Rep

Test

Mailing Address

Fake Address

City

State

Z IP/Postal Code Country - if outside the U.S.

Fake City

Maryland

Phone Number

Alternate Phone Number (Optional)

111-222-3333

1112223333

I

12345

Section 5 - Representative's Status, Affiliations, and Certifications
Representative's Status Part A - Type of Representative (Representatives have a duty to keep their information current)

12] 1am an attorney (SSA law states that an attorney is someone in good standing who has the right to practice law before a
court of a State, Territory, District, or island possession of the United States, or before the Supreme Court or a lower
Federal court of the United States.)

DI am a non-attorney eligible for direct payment (SSA Jaw requires that non-attorneys meet certain criteria to qualify for direct
payment. Refer to our website at www.ssa.gov/representation for criteria).

D I am a non-attorney not eligible for direct payment

D I work for a non-profit organization (e.g. a law clinic or state legal aid)
Representative's Status Part B - Disqualification

I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice law.
fl!Yes □ No

I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.

12:J Yes D

No

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II)

a

X

Claimant's Social Security Number

Appointed Representative's Rep ID

111-22-3333

I1 23456789A
Section 5 - Continued
Affiliation Information

If you are representing the claimant(s) as a partner or employee of a business entity, firm or other organization you may provide
your Employer Identification Number (EIN) here, if one exists for tax purposes. This number is not your Social Security Number
(SSN). This is your employer's tax identification number. (Do not complete this section if you do not qualify for direct payment.)
EIN

I123456789

Organization's Name (Enter the full name of the business, entity, firm or organization with which you want to be affiliated v.hile
representing this claim)

Test Organization
Representative's Business Address (if different than mailing address)

Test Address
City

State

ZIP/Postal Code

Test City

Maryland

12345

Country - if outside the U.S.

Representative's Certifications
I accept this appointment and certify the following :
• I understand and agree that I will comply with SSA's laws and rules o n the representation of parties, including the Rules of
Conduct and Standards of Responsibility for Representatives; I will not charge, collect. or retain a fee for representational
services that SSA has not approved or that is more than SSA approved unless a regulatory exclusion applies.
• I understand that if I fail to comply with any of SSA's laws and rules I may be suspended or d isqualified as a representative
before SSA.
• I will not disclose any information to any unauthorized party without the claimant's specific written consent.
• I am not currently suspended or prohibited, for any reason. from practicing 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.
• I accept appointment as the representative for the claimant named in Section 2 of this form in connection with the claims and
asserted rights described in Section 6 of this form.
• I agree that a copy of this signed form SSA-1696 will have the same force and effect as the original.
• I declare under penalty of perjury that I hav e examined all of the information on this form and on all accompanying statements or
forms, including any information, attestations and certifications provided to SSA in registration, and that they are all currently true
and correct to the best of my knowledge.

If I intend to seek direct payment of the authorized fee on this claim • I have registered for and obtained a Rep ID, and my registration information is up-to-date.
• I have provided up-to-date information on my registration concerning whether I have been suspended or prohibited from practice
before SSA or any other Federal program or agency, disbarred or suspended by a court or bar, and convicted of a violation
under Section 206 or 1631(d) of the Social Security Acl

I CERTIFY TO ALL OF THE ABOVE

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Appointment of Representative

Form SSA-1696-APP (02-2021) UF

II>

X

Page 6 of 6

Claimant's Social Security Number

I

a

Appointed Representative's Rep ID

I

111-22-3333

I123456789A

I

Section 6 - Claim Type
I appoint the individual named in Section 4 to act as my representative in connection with my claim(s) or asserted right(s) under
litle II (RSDI), litle XVI (SSI}, litle XVIII (Medicare Coverage), and Title VIII (SVB} of the Social Security Act, as presently
amended, specifically for the issues identified below: (Select YES for all that apply}
Yes

No

ID ~
lo ~

Claim/Appeal for Title II Disability Benefits
Claim/Appeal for Title XVI Disability Benefits

ID

~ Concurrent Title II and Title XVI Disability Benefits

[]

~ Claim/Appeal for Retirement Benefits

lo

~ Claim/Appeal for Title XVIII (Medicare}, VIII (Special Veteran's Benefits)

~

ID

ll2I ID

Continuing Disability Review (CDR}
Post-Entitlement Issue (a new issue you raise after eligibility for other benefits)

Other Information
(E.g., benefit amount, month of entitlement, representative payee, suspension, termination, overpayment)

I

Section 7 - Fee Arrangement

Check one box below:

□

I will request a fee and d irect payment of this fee . Select this box if you are eligible for direct payment and want us to
withhold a portion of the past-due benefits to pay you the fee we may authorize. (We must authorize the fee.)

□

I will request a fee but not direct payment. Select this box if you are not eligible for direct payment from the past-due
benefits, or if you do not want direct payment. You must collect any fee we may authorize on your own. (We must
authorize the fee.)

□

I waive the right to receive a fee from th e claimant. any auxiliary beneficiaries or any oth er individual. Select this
box if you certify that an entity, or a Federal, state, county, or city government agency will pay the fee and any expenses
from its funds. The claimant, auxiliary beneficiaries, or other individuals must not be liable for the fee, directly or indirectly,
in whole or in part, or any expenses. (We do not need to authorize the fee if afl regulatory condmons apply.)

~ I waive the right to a fee.

I

Section 8 - Signatures

Representative's Signature

Date

TMt ReJJ

Mar 3, 2021

Claimant's Signature

Date

*Click here to sign

Mar 3, 2021

Test Rep (Mar l . 2021 06:25 EST)

You will need to electronically sign the document to complete your form. This form must be signed by the Appointed Representative
and the Claimant to be processed.

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Form SSA-1696-APP (02-2021) UF

Page 6 of 6

Claimant's Social Security Number

Appointed Representative's Rep ID

1 111-22-3333

I123456789A
Section 6 - Claim Type

I appoint the individual named in Section 4 to act as my representative in connection with my claim(s) or asserted right(s) under
litle II (RSDI), litle XVI (SSI}, litle XVIII (Medicare Coverage), and Title VIII (SVB} of the Social Security Act, as presently
amended, specifically for the issues identified below: (Select YES for all that appl y}
Yes

No

ID
ID

~

~ Claim/Appeal for Title XVI Disability Benefits

ID

~

Claim/Appeal for Title II Disability Benefits

Concurreflt Title II and Title XVI Disability Benefits

ID 10

Claim/Appeal for Retirement Benefits

ID

Claim/Appeal for Title XVIII (Medicare}, VIII (Special Veteran's Benefits)

~

ID
lfll ID
~

Continuing Disability Review (CDR}
Post-Entitlement Issue (a new issue you raise after eligibility for other benefits)

Other Information
(E.g., benefit amount, month of entitlement, representative payee, suspension, termination, overpayment)

Section 7 - Fee Arrangement
Check one box below:

cl

I will request a fee and direct payment of this fee. Select this box if you are eligible for direct payment and want us to
withhold a portion of the past-due benefits to pay you the fee we may authorize. (We must authorize the fee.)

C] I will request a fee but not dir ect payment. Select this box if you are not eligible for direct payment from the past-due
benefits, or if you do not want direct payment. You must collect any fee we may authorize on your own. (We must
authorize the fee.)

D

I waive the right to receive a fee from th e claimant. any auxiliary benefi ciaries or any other i ndividual. Select this
box if you certify that an entity, or a Federal, state, county, or city government agency will pay the fee and any expenses
from its funds. The claimant, auxiliary beneficiaries, or other individuals must not be liable for the fee, directly or indirectly,
in whole or in part, or any expenses. (We do not need to authorize the fee if all regulatory condmons apply.)

fl] I waive the right to a fee.
Section 8 - Signatures
Representative's Signature

Date

Te,rt Rep

Mar 3, 2021

Claimant's Signature

Date

Test Rep (Marl, 2021 0!l::25 EST)

_ Ti
-<-e"m-=--=-..,_-=~==
· -=-=-=---- - - - - - - - - - - - - ------l Mar 3, 2021
Test Claimant

Mar 3 2021

You will need to electronically sign the document to complete your form. This form must be signed by the Appointed Representative
and the Claimant to be processed.

By signing, I agree to both this agreement and the Consumer Disclosure. My use ofAdobe
.
.
Sign ,s governed by the Adobe Terms of Use.

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You finished signing "Appointment of Representative".
All parties will be notified via email. You can also download a copy of what you just
signed.

9

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You finished signing "Appointment of Representative".
All parties will be notified via email. You can alsd download a copy pf what you just
signed.

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Enter Password:

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[EXTERNAL] Appointment of Representative has been Signed
To

cc

Claimant's & Representative's
Email Addresses

Retention Policy Delete_7_Year_Default (J years)

0

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1/28/2028

If there are problems with how this message is displayed, click here to view it in a web browser.

2 Recipients (2 Completed)
> Activity

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Form SSA-1696-APP (02-2021) UF
Disconti nue Prior Editions Social
Security Administration

Appointment of Representative
Page 1 of 6
0MB No. 0960-0527

Created Mar 03, 2021 8:02 AM

1111

From: Social Security Administration (no-

Instructions for Completing Form SSA-1696

reply@)ssa.gov)

Follow the link we send you after you submit the form to print and/or save a copy of this form for your records

Status: Signed

YOU DO NOT HAVE TO SIGN THIS FORM - Use and sign this form to appoint an individual to act on your behalf in your claim
pending with us. If you do not agree with any information on th is form , do not sign it. Refusing to sign the form will not affect how we
process and decide your claim.

Message: THIS LINK EXPIRES IN s

CALENDAR DAYS. You have a document to
review and sign. You can access the

You may only file this electronic vers ion of Form SSA-1696 if you have a claim or other issue pending with us. In this document,
"you" means the claimant, beneficiary, auxiliary, or spouse. "Us" and "SSA" means the Social Security Administration.

document using the link above. For additional
security, the representative has set an open

If you suspect Social Security Fraud - If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the Inspector
General's Fraud Hotline at 1-800-269-0271 TTY 1-866-501-2101 .

___ ,.., ........ .J t ...... .a.L: ... .J .... _ ,, ___ .1, it ........ - - - __ .._

See more

General Information About This Form
• You may appoint a qualified representative of your choice to represent you on any claim or asserted right under any of our
programs. For more information on who can qualify to be an appointed representative, when your representative's
appointment begins or ends, payment of fees to appointed representative(s), and other helpful information, you can visit our
website at www.ssa.gov/representation, or call us, toll-free, at 1-800- 772-1213. To find other helpful information or the
address and telephone number for your local Social Security field office, you can visit www.ssa.gov/locator.
• You may use this electronic version of Form SSA-1696 to appoint a representative. However, we do not require you to use
this electronic version; you can still use the paper version to tell us about your appointment. After you read, complete, and
electronically sign the form, you must click "Click to Sign" to send us this form, or your appointment will not reach us. If we
successfully process your appointment, we will send you a notice to tell you. You do not need to submit a paper form if you
submit this electronic version.
• You may also choose to be unrepresented. We handle your case in the same manner whether you are represented or
unrepresented. You do not need to appoint someone who simply helps you through the process. For example, you do not need to
appoint someone who helps you call us, reads to you from documents, or interprets for you if you speak another language. You
only need to appoint someone if he or she will be acting or appearing on your behalf, or will be making decisions about your case

Actions

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for you. If you choose to be unrepresented (or do not want to appoint the individual identified on this electronic form), do not
complete or submit this form.
• You and your representative(s) must give us accurate information as quickly as possible. Providing misleading or false evidence
on this form or your application, or withholding or delaying giving us evidence, could lead to possible criminal charges or
administrative sanctions against you or your representative.
Appointing a Representative
Before completing your sections of this electronic form, please review the sections that you can view that were completed by the
representative. If you agree with all of the information already entered, complete the highlighted sections, electronically sign and date
the form In Section 8, and submit it to us by clicking "Click to Sign." After you submit the form successfully, you will receive an email
from adobesign@adobesign.com with a link that will take you to a copy of the completed form that you can keep for your records. If
you are appointing multiple representatives, you must use a separate form for each representative.

>

2 Recipients (2 Completed)

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Activity

Section 1 - Claimant's Information and Number Holder's Information
Your representative will complete your name. You must complete all of the other information, including your Social Security number.
If you are filing your action on someone else's Social Security record, this person is the "number holder'' and we need his or her
information to process your claim.
Section 2 - Authorization for Disclosure
By selecting the disclosure box, you are authorizing us to give information to your representative's staff, partners, associates,
and other individuals who work for or with your representative (such as contractors and copying services) about you and your pending
case. We will check the credentials of the individuals requesting information on behalf of your representative for authentication
purposes.
Section 3 - Principal Representative
If you appoint or have appointed multiple representatives, you must name your principal representative who will be our main point of
contact. We will send copies of your notices to this individual and communicate directly with him or her.
Section 4 - Representative's Information
Your representative must complete this section and submit this form by clicking "Click to Sign." It is important that he or she fill in all
the boxes in this section, including the Representative Identification Number (Rep ID) if he or she has one.

...
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1111

Form SSA-1696-APP (02-2021) UF

Page 2 of 6

Appointment of Representative
Created Mar 03, 2021 8:02 AM

Section 5 - Representative's Status, Affiliations, and Certifications
Your representative must complete this section to let us know his or her status as a professional. If your representative is seeking
a fee and is working for an employer, entity, or firm, he or she must also complete the affiliation section and give us the
Employer's Identification Number (EIN) . We will provide both your representative and the employer, entity, or firm information of
the reported income. For more information about your representative's reported income and employer reg istration, visit our
website at www.ssa.gov/representation. Your representative must certify the accuracy of all statements in th is section.

From: Social Security Administration (no-

reply@)ssa.gov)
Status: Signed

Section 6 - Claim Type
The representative completes this section. Your representative will check the boxes for the types of daims you will be appointing
them to represent you.

Message: THIS LINK EXPIRES IN s
CALENDAR DAYS. You have a document to

Section 7 - Fee Arrangement
Generally, to charge a fee for services, your representative must get our approval. Your representative may waive the right to
charge you a fee or tell us that a third party entity (business, government agency, or organization) will pay the fee . In these
situations, the third party must pay out of its own funds the fee and any expenses, and you and any auxiliary beneficiaries (e.g.,
children or spouse) must be free of responsibility to pay any fees or expenses. If your representative is eligible for direct payment,
he or she also may waive the right to direct payment.

review and sign. You can access the
document using the link above. For additional
security, the representative has set an open
___ ,.., ......... .J t ...... .a.L: ... .J .... _ ,, ___ .a. it ........ - - - __ .._

See more

Section 8 - Signatures
You must electronically sign and date this section and send the completed form to us by dicking the "Click to Sign" button.
Remember, by signing this form you are appointing the named individual as your representatiive and authorizing us to disclose to
him or her any information relevant to your claim(s) as if he or she were you. If you select the box in section 2, we may also disdose
the same information to your appointed representative's associates.

Actions

Privacy Act Statement - Collection and Use of Personal Information
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 appointing a representative to act on your
behalf.

~

Download PDF

Po

Download Audit Report

We will use the information to verify the appointment of your representative and his or her acceptance of the appointment. We may
also share your information for the following purposes, called routine uses:

~

Add Notes

• 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 Federal, State, and local law enforcement agencies and private security contractors, as appropriate, information
necessary:
(a)
to enable them t o 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.

>

2 Recipients (2 Completed)

>

Activity

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 October 31, 2019, at 84 FR 58422; 60-0320, entitled Electronic
Disability Claim File, as published in the FR on June 4, 2020, at 85 FR 34477; 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, is
available on our website at www.ssa.g ov/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
• 18 U .S.C . §§ 203, 205, and 207; 42 U.S.C. §§ 406, 1320a-6 , 1383(d)(2) and 1631;
• 26 U .S.C . §§ 6041 and 6045(f) and 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq.

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Form SSA-1696-APP (02-2021) UF
Discontinue Prior Editions Social
Security Administration

Appointment of Representative
Page 3 of 6

Claimant's Social Security Number

1111

Created Mar 03, 2021 8:02 AM

0MB No. 0960-0527
Appointed Representative's Rep ID

1111-22-3333

From: Social Security Administration (no-

reply@)ssa.gov)

I123456789A

Claimant's Appointment of a Representative

Status: Signed
Message: THIS LINK EXPIRES IN s

Section 1 - Claimant's Information
I

First Name

CALENDAR DAYS. You have a document to

Initial Last Name

Test

review and sign. You can access the

Claimant

document using the link above. For additional

Mailing Address

security, the representative has set an open

Test Address

----•••---.J t - .. .&.L : ... .J .... _ ,, ___ .1, it ........ - -- --"'-

See more
City

ZIP/Postal Code Country - if outside the U.S.

State

Test City

Maryland

Actions

12345

Alternate Phone Number (Optional)

Phone Number

11 1-222-3333

1112223333

I

I

.

Number Holders
' Information (Complete when appltcable)

~

Download PDF

Po

Download Audit Report

~

Add Notes

My claim is based on another person's work or earnings (e.g., spouse or parent). This person's information is different from mine.
Number Holder's Social Security Number

>

2 Recipients (2 Completed)

>

Activity

1999887777
First Name

llnitiall Last Name

Person

Test

Section 2 - Disclosure (Claimant Only)

D By selecting this box, I, the claimant listed in Section 1, whose signature appears in Section 8, authorize SSA to release
information in relation to my pending claim(s) or asserted right(s) to designated associates who perform administrative duties
(e.g., clerks, assistants), partners, or parties under contractual arrangements for or with my representative. (The appointed
representative 's partners, associates, delegates and designees must be prepared to provide information in order to be
authenticated.)

Section 3 - Principal Representative (Claimant only - Complete when applicable)
I have appointed before, or appoint now, more than one representative. I ask SSA to make contacts or send notices to this
individual. My principal representative is:
Name Test Name Here

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Form SSA-1696-APP (02-2021) UF

Page 4 of 6
Appointed Representative's Rep ID

Claimant's Social Security Number

I111 -22-3333

Appointment of Representative
Created Mar 03, 2021 8:02 AM

1123456789A

From: Social Security Administration (no-

Section 4 - Representative's Information

reply@)ssa.gov)

Representatives who are eligible and seek direct payment of their fee must register and receive a Rep ID before the appointment.
For more information about registration visit us on-line at www.socialsecurity.gov/ar, contact us at 1-800-772-1213
(TTY 1-800-325-0778), or visit your local Social Security office.

Status: Signed

First Name
1

Test

Message: THIS LINK EXPIRES IN s

•nm, 1I ~~ Nam,

CALENDAR DAYS. You have a document to
review and sign. You can access the
document using the link above. For additional

Mailing Address

security, the representative has set an open

Fake Address

----•••---.J t- .. .&.L: ... .J .... _ ,, ___ .1, it ........ - -- --"'-

See more
City

ZIP/Postal Code Country - if outside the U.S.

State

Fake City

Maryland

12345

Phone Number

Alternate Phone Number (Optional)

111 -222-3333

11 12223333

I......_

Actions

~

Download PDF

Po

Download Audit Report

~

Add Notes

Section 5 - Representative's Status, Affiliations, and Certifications

Representative's Status Part A - Type of Representative (Representatives have a duty to keep their Information current)

01 I am an attorney (SSA law states that an attorney is someone in good standing who has the right to practice law before a
court of a State, Territory, District, or island possession of the United States, or before the Supreme Court or a lower
Federal court of the United States.)

>

2 Recipients (2 Completed)

>

Activity

D I am a non-attorney eligible for direct payment (SSA law requires that non-attorneys meet certain criteria to qualify for direct
payment. Refer to our website at www.ssa.gov/representation for criteria).

D I am a non-attorney not eligible for direct payment.
O I work for a non-profit organization (e.g. a law clinic or state legal aid)
Representative's Status Part B - Disqualification
I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice law.

fZI Yes D No
I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.

IZI Yes D No

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...
~
1111

Form SSA-1696-APP (02-2021) UF

Page 5 of 6

Claimant's Social Security Number

Appointment of Representative

Appointed Representative's Rep ID

I111-22-3333

Created Mar 03, 2021 8:02 AM

1123456789A

From: Social Security Administration (no-

Section 5 - Continued

reply@)ssa.gov)

Affiliation Information

Status: Signed

If you are representing the claimant(s) as a partner or employee of a business entity, firm or other organization you may provide
your Employer Identification Number (EIN) here, if one exists for tax purposes. This number is not your Social Security Number
(SSN). This is your employer's tax identification number. (Do not complete this section if you do not qualify for direct payment.)
EIN

Message: THIS LINK EXPIRES IN s
CALENDAR DAYS. You have a document to
review and sign. You can access the

1123456789

document using the link above. For additional

Organization's Name (Enter the full name of the business, entity, firm or organization with which you want to be affiliated while
representing this claim)

security, the representative has set an open
___ ,.., ......... .J t ...... .a.L: ... .J .... _ ,, ___ .a. it ........ - -- __ .._

Test Organization

See more

Representative's Bu siness Address (if different than mailing address)

Test Address
City

State

ZIP/Postal Code

Test City

Maryland

12345

Actions

~

Download PDF

Po

Download Audit Report

~

Add Notes

Country - if outs ide the U.S.

Representative's Certifications
I accept this appointment and certify the following :
• I understand and agree that I will comply with SSA's laws and rules on the representation of parties, including the ~ules of
Conduct and Standards of Responsibility for Representatives; I will not charge, collect, or retain a fee for representational

>

2 Recipients (2 Completed)

>

Activity

services that SSA has not approved or that is more than SSA approved unless a regulatory exclusion applies.
• I understand that if I fail to comply with any of SSA's laws and rules I may be suspended or disqualified as a representative
before SSA.
• I will not disclose any information to any unauthorized party without the claimant's specific written consent.
• I am not currently suspended or prohibited, for any reason, from practicing 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.
• I accept appointment as the representative for the claimant named in Section 2 of th is form in connection with the claims and
asserted rights described in Section 6 of this form.
• I agree that a copy of this signed form SSA-1696 will have the same force and effect as tlhe original.
• I declare under penalty of perjury that I have examined all of the information on this form and on all accompanying statements or
forms, including any information, attestations and certifications provided to SSA in registration, and that they are all currently true
and correct to the best of my knowledge.

If I intend to seek direct payment of the authorized fee on this claim • I have registered for and obtained a Rep ID, and my registration informati on is up-to-date .
• I have provided up-to-date information on my registration concerning whether I have been suspended or prohibited from practice
before SSA or any other Federal program or agency, disbarred or suspended by a court or bar, and convicted of a violation
under Section 206 or 1631 (d) of the Social Security Act.

I CERTIFY TO ALL OF THE ABOVE

~

(Representative's Initials)

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Ila
1111

Form SSA-1696-APP (02-2021) UF

Page 6 of 6

Claimant's Social Security Number

Appointment of Representative

Appointed Representative's Rep ID

1111-22-3333

Created Mar 03, 2021 8:02 AM

I123456789A

From: Social Security Administration (noreply@)ssa.gov)

Section 6 - Claim Type

Status: Signed

I appoint the individual named in Section 4 to act as my representative in connection with my claim(s) or asserted right(s) under
Title II (RSDI) , Title XVI (881), Title XVIII (Medicare Coverage), and Title VIII (SVB) of the Social Security Act, as presently
amended, specifically for the issues identified below: (Select YES for all that apply)

Message: THIS LINK EXPIRES IN s
CALENDAR DAYS. You have a document to

Yes

No

□
□
□
□
□
l2il
l2il

fZI

Claim/Appeal for Title II Disability Benefits

JZI

Claim/Appeal for Tille XVI Disability Benefits

IZI
IZI
IZI
Cl

Concurrent Title II and Title XVI Disability Benefits

Cl

Post-Entitlement Issue (a new issue you raise after eligibility for other benefits)

review and sign. You can access the
document using the link above. For additional
security, the representative has set an open
___ ,.., ......... .J t ...... .a.L : ... .J .... _ ,, ___ .a. it ........ - - - __ .._

See more

Claim/Appeal for Retirement Benefits
Claim/Appeal for Tille XVIII (Medicare), VIII (Special Veteran's Benefits)

Actions

Continuing Disability Review (CDR)

Other Information
(E.g., benefit amount, month of entitlement, representative payee, suspension, termination, overpayment)

Section 7 - Fee Arrangement
Check one box below:

Cl

I will request a fee and direct payment of this fee. Select this box if you are eligible for direct payment and want us to
withhold a portion of the past-due benefits to pay you the fee we may authorize. (We must authorize the fee.)

CJ

I will request a fee but not direct payment Select this box if you are not eligible for direct payment from the past-due
benefits, or if you do not want direct payment. You must collect any fee we may authorize on your own. (We must
authorize the fee.)

D

I waive the right to receive a fee from the claimant, any auxiliary beneficiaries or any other individual. Select this
box if you certify that an entity, or a Federal, state, county, or city government agency will pay the fee and any expenses
from its funds. The claimant, auxiliary beneficiaries, or other individuals must not be liable for the fee, directly or indirectly,
in whole or in part, or any expenses. (We do not need to authorize the fee if all regulatory conditions apply.)

~

Download PDF

Po

Download Audit Report

~

Add Notes

>

2 Recipients (2 Completed)

>

Activity

fZ) I waive the right to a fee.

Section 8 - Signatures
Date

Representative's Signature

nt

Mar 3, 2021

Claimant's Signature

Date

rw c/ahuwt:

Mar 3, 2021

Test Claimant (Mar 3, 2021 08:29 EST)

You will need to electronically sign the document to complete your form. This form must be signed by the Appointed Representative
and the Claimant to be processed.

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Fri 1/29/2021 1:40 PM

Social Security Administration
[EXTERNAL]

Reminder: Waiting for you to sign Appointment of Representative

To Representative o r Claimant's Email Address

Ret ention Policy Delete_7_Year_Default (7 years)

0

Expires

1/28/2028

If t here are problems wit h how this message is displayed, click here to view it in a web browser.

Please sign Appointment of
Representative
Click here t o review and sign Appointment of
Representative.
After you sign Appointment of Representative, all
parties will be notified.

Social Security Administration has requested that this
reminder be sent. This reminder will be re-sent every
day until completed. Cli ck here if you wish to stop
receiving reminders about this agreement.
This document is available for signing until February 2,
2021 and will expire thereafter.

To ensure that you continue receiving our emails, please acid adobesie,,@adobesign.com to your address book or safe list.

Appointment of Representative
Final Audit Report

2021-01-15

Created:

2021-01-15

By:

Social Security Administration (no-reply@ssa.gov)

Status:

Signed

Transaction ID:

CBJCHBCAABAADhN7-_aghfqptX6t1 G0BaJEZSFDgF6DH

"Appointment of Representative" History
~ Document created by Social Security Administration (no-reply@ssa.gov)
2021-01-15 - 3:37:05 PM GMT- IP address: 137.200.38.21

i

Social Security Administration (no-reply@ssa.gov) set a password to protect the signed document.
2021-01-15 - 3:37:05 PM GMT

~ Document emailed to Test Rep (no-reply@ssa.gov) for signature
2021-01-15 - 3:37:08 PM GMT

~ Email viewed by Test Rep (no-reply@ssa.gov)
2021-01-15 - 3:45:46 PM GMT- IP address: 137.200.0.11 2

0'c,

Document e-signed by Test Rep (no-reply@ssa.gov)
Signature Date: 2021-01-15 - 3:46:48 PM GMT - Time Source: server- IP address: 137.200.0.1 12

~ Document emailed to Test Claimant (karrie.dash@ssa .gov) for signature
2021-01-15 - 3:46:49 PM GMT

~ Email viewed by Test Claimant (karrie.dash@ssa.gov)
2021-01-15 - 3:48:56 PM GMT- IP address: 137.200.0.11 2

0o

Document e-signed by Test Claimant (karrie.dash@ssa.gov)
Signature Date: 2021-01-15 - 3:52:22 PM GMT - Time Source: server- IP address: 137.200.0.1 12

0

Agreement completed.
2021-01-15 - 3:52:22 PM GMT

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