Appointment of Representative - SSA-1696

Appointment of Representative

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0527 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-1696 Appointment of Representative - SSA-1696 Form and Instruction
e1696 - Revised Screen Package.pdf www.ssa.gov Other-e1696 Submittable PDF Screens
e1696 - Revised Screen Package.pdf www.ssa.gov Other-e1696 Submittable PDF Screens
SSA-1696 Appointment of Representative SSA-1696.pdf www.ssa.gov Form and Instruction
SSA-1696 Appointment of Representative SSA-1696.pdf www.ssa.gov Form and Instruction
e1696 - Current Screen Package.pdf Current e1696 Screens IC Document
e1696 - Current Screen Package.pdf Current e1696 Screens IC Document

Information Collection (IC) Details

IC Title:	Appointment of Representative - SSA-1696	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 414.1725 20 CFR 416.1507 20 CFR 410.684 20 CFR 404.1720 20 CFR 404.1707

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-1696	Appointment of Representative	SSA-1696.pdf	www.ssa.gov	Yes	No	Fillable Printable
Other-e1696 Submittable PDF Screens			e1696 - Revised Screen Package.pdf	www.ssa.gov	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 800,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	800,000	800,000
Annual IC Time Burden (Hours)	160,000	160,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current e1696 Screens	e1696 - Current Screen Package.pdf	09/27/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.