Form SSA-1693 Fee Agreement for Representation before the Social Secur

Form SSA-1693 (X/XX/2021)
Social Security Administration

OMB No. 0960-0810

INSTRUCTIONS FOR COMPLETING FORM SSA-1693
Once you complete it, keep a copy of this form for your records.

File Form SSA-1693 only if you are submitting or have submitted a notice of appointment (i.e., SSA-1696 or equivalent writing)
on an active claim or issue pending decision with us.
In this document, “you” means the claimant, beneficiary, auxiliary beneficiary or spouse. In this document, “us” and “SSA”
means the Social Security Administration.
Requesting a fee for representational services
Your appointed representative can ask for a fee for the services he or she provided in your claim. Not all representatives ask for
a fee, and some only charge a fee if they win your case. To charge you a fee for services related to your claim(s), your
representative(s) generally must get our approval. Your representative can get our approval by submitting a fee agreement
(you may use this form) or a fee petition. You and your representative choose which of these two processes to use. Under the
fee agreement process, the amount your representative can ask for is limited by the Social Security Act. Under the fee petition
process, your representative can ask for a higher fee. For more information on fees, fee processes, and our rules, visit our
website at www.ssa.gov/representation.

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Registration
Representatives who seek direct payment of their fee must first register with us. For more information on representative
registration, visit us online at www.ssa.gov/ar, contact us at 1-800-772-1213 (TTY 1-800-325-0778), or contact your local Social
Security office.
When to file a fee agreement
Your representative(s) must file your fee agreement before we issue a favorable decision in your case. If you or your
representative(s) submit the fee agreement after our decision, we will disapprove your fee agreement.

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What you have to pay
Under the terms of a fee agreement, you agree to pay an amount up to 25 percent of your total past-due benefits or an amount
set by us, whichever is less. You must pay the fee we authorize. Your spouse, dependents, or your auxiliary beneficiaries will
also pay a fee unless they have their own representation. In addition to the fee we authorize, you may also have to pay:
• Fees authorized by a Federal court for services your attorney provided during court proceedings, and
• Any “out-of-pocket” expenses your representative may incur (e.g., costs for making copies of a doctor's or hospital's
records). Note: These fees and expenses do not require our authorization.

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Two-tiered fee agreements
You and your representative(s) should complete this field only if you want to limit the effect of this fee agreement to a certain
administrative level. If you choose this option and your case is appealed beyond the specified administrative level, your
representative(s) can file a fee petition. Under the fee petition process, the authorized fee may be higher than the amount that
can be authorized under the fee agreement process.
Trust or escrow accounts
Your representative may accept money from you before we authorize a fee as long as he or she holds it in a trust or escrow
account according to our rules and policy. If you choose to enter into the trust or escrow agreement with your representative, you
may willingly deposit the money in the trust or escrow account and tell us on this form. Only complete this field if your
representative is using an escrow or trust account.
Third-party payments
We collect information on payments your representative may receive from a third party for services he or she provided to you
during the administrative proceedings. These fees may be in lieu of your fee payment, or may be in addition to your payment. We
may consider these payments during our authorization process to determine if we need to authorize these fees under our rules.
All statutory and regulatory rules continue to apply in situations involving third-party payments.
Withholding of funds and direct payment to your representative
If your representative is eligible under our rules to receive an authorized fee directly from us out of your past-due benefits, we
usually withhold 25 percent of your past-due benefits for direct payment of that fee. However, you are responsible for paying your
representative the authorized fee if:

• the amount of the fee we approve is more than the amount held for you in a trust or escrow account, or more than the amount
we can pay to your representative from your past-due benefits,

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Form SSA-1693 (3/XX/2021)
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we did not withhold past-due benefits,
your claim did not result in past-due benefits,
your representative is not eligible under our rules for direct payment of the fee from us,
your representative waived direct payment of the fee from us,
you ended the appointment of the representative before we issued a favorable decision,
your representative withdrew from representing you before we issued a favorable decision,
your representative was disqualified or suspended from acting as a representative before we issued the direct payment,
your representative did not submit a valid fee agreement before the first favorable decision in your claim or did not:
○ ask for our approval of a fee with a fee petition until 60 days after the date of your notice of award, or
○ timely tell us that he or she planned to ask for a fee with a fee petition.

Signatures
You and your representative(s) must sign and date this form. If you are appointing multiple representatives, all of your
representatives who intend to seek a fee for services provided on your claim(s) must sign on a single fee agreement for the fee
agreement to be approved. They may use the last page for this purpose.
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 affect the amount of fees authorized for
services rendered before us.

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We will use the information you provide to authorize fees for services rendered to the claimant named on the form. We may also
share your information for the following purposes, called routine uses:
To a claimant’s representative to the extent necessary to dispose of a fee petition or fee agreement; except for predecisional deliberative documents, such as analyses and recommendations prepared for the decision-maker;

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To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration of
its programs; and

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To the Internal Revenue Service and to State and local government tax agencies in response to inquiries regarding receipt of
fees we paid directly starting in calendar year 2007.

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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) 60-0003, entitled Attorney Fee
File, as published in the Federal Register (FR) on January 11, 2006, at 71 FR 1803; 60-0089, entitled Claims Folders System, as
published in the FR on October 31, 2009, at 84 FR 58422; 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 (OMB) control number. We estimate that it will take about 7 minutes to read the instructions, gather the facts, and
answer the questions. You may send us comments on our time estimate to SSA, 6401 Security Boulevard, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
References
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18 U.S.C. §§ 203, 205, and 207,
26 U.S.C. §§ 6041 and 6045(f)
42 U.S.C. §§ 406(a), 1320a-6, and 1383(d)2)
20 CFR §§ 404.1700 et seq. and 416.1500 et seq.

OMB No. 0960-0810

Form SSA-1693 (X/XX/2021)

Fee Agreement for Representation Before the Social Security Administration
General Information
You may use this form to file an agreement between you and your representative(s) to seek our authorization of the fee your
representative(s) may charge you for services your representative(s) provides before us. Section 206 of the Social Security Act
limits the fee we authorize under a fee agreement to 25 percent of your past-due benefits or a maximum dollar amount we set,
whichever is less. This form does not limit you and your representative(s) from agreeing to any additional terms unrelated to the
fee. Requesting, receiving, or keeping a fee in excess of the legal limit or in excess of what we authorize is unlawful and may
lead to sanctions for your representative(s). Unless they have their own representation, your dependents, spouse, or auxiliary
beneficiaries will also be liable for a fee under this fee agreement if we approve benefits for them.

Representative's Information
Representative's ID (RepID)

Initial Last Name

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First Name

City

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Mailing Address

State

Phone Number

ZIP/Postal Code

Alternate Phone Number (Optional)

Phone Number

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Country/Area Code

Country/Area Code

Phone Number

Claimant's Information

Claimant's Social Security Number

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First Name

Initial Last Name

Mailing Address

City

State

Phone Number
Country/Area Code

ZIP/Postal Code

Alternate Phone Number (Optional)
Phone Number

Country/Area Code

Phone Number

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Form SSA-1693 (X/XX/2021)
Representative's ID (RepID)

Claimant's Social Security Number

Standard Fee Agreement
If the Social Security Administration (SSA) favorably decides my claim(s) and the decision results in past-due benefits, section
206(a)(2) of the Social Security Act permits me to agree to pay my representative(s) a fee that does not exceed the lesser of 25
percent of my past-due benefits or the maximum dollar amount set by the Commissioner of Social Security on the date SSA
authorizes my representative’s fee. The maximum amount is $6,000 as of the publication of this form.
Choose One:
I agree to pay the maximum fee as stated in the preceding paragraph.

or

I agree to pay less than the maximum: $

%.

I understand that I, my eligible spouse, any affected auxiliary beneficiary, my representative or the decision maker have the right to
protest the fee authorized under this fee agreement, in writing, within 15 days from the authorization.

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I understand that my representative may still request a fee even if my case does not result in past-due benefits, or the decision is not
favorable. If the fee agreement cannot be approved because there are no past-due benefits or for other reasons, my representative
may file a fee petition to request that SSA authorize a fee. I also understand that if there are no past-due benefits withheld, if not
enough past-due benefits are withheld, or if my representative is not eligible for direct payment by SSA, I will be responsible to pay the
authorized fee to my representative directly. SSA is not responsible for authorizing out-of-pocket costs and expenses for which I may
be responsible to pay directly to my representative.
Claimant's Initials

Two-Tiered Fee Agreement (Optional)

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Only complete this section if you and your representative(s) have chosen to limit the effect of this fee agreement to a certain
administrative level.
Check only if applicable:
This fee agreement is in effect through this administrative level: Initial______ Reconsideration ______ Hearing ______
I understand that a two-tiered fee agreement is not required, but if chosen and SSA favorably decides my claim(s) above the
administrative level indicated above, SSA will disapprove this fee agreement and my representative(s) may ask SSA to authorize
a fee by filing a fee petition.

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Escrow/Trust Accounts or Third-Party Payments (Optional)

Only complete this section if your representative(s) will use an escrow or trust account, or someone other than you or your
spouse, dependents, or auxiliary beneficiaries or another individual has or will pay your representative a fee.
Check only if applicable:

With my consent, my representative(s) has/have or will establish an escrow or trust account in the amount of $ ___________
My representative(s) will receive a fee from another party (e.g., state, county, private entity) of $ _________________
and I will have no financial responsibility to pay any fee, unless SSA authorizes the total fee (i.e., the total amount paid by the
third party, me and/or my spouse, dependents, or auxiliary beneficiaries).

Claimant and Representative Signatures
Only representatives who have been properly appointed can be authorized to receive a fee. The claimant and any appointed
representative(s) not waiving a fee are each required to sign this fee agreement. Other representatives can also sign the form.

Claimant's Signature

Date

Representative's Signature

Date

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Form SSA-1693 (X/XX/21)
Representative's ID (RepID)

Claimant's Social Security Number

Additional Signatures
This page is optional - Use only if multiple representatives want to sign on the same fee agreement.

Representative's Rep ID (when applicable)

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Additional Representative's Name and Signature