Form SSA-1699 Registration for Appointed Representative Services and D

Form SSA-1699 (xx-xxxx)
Destroy Prior Editions
Social Security Administration

Page 1 of 6
OMB No. 0960-0732

Instructions for Completing Form SSA-1699
General Information About This Form
In this document, “you” means the representative. “We” or “us” means the Social Security Administration.
YOU DO NOT NEED TO COMPLETE THIS FORM if you have not received a notice from us about e-folder
access and will not be requesting direct payment of any authorized fees. Generally, you will not need to
complete this form if you are not in the business of providing services to Social Security claimants and
beneficiaries, but will be appointed as a representative for a relative, friend, or other acquaintance.
•

Complete this form if you:
(1) previously registered as a representative and need to update your information,,
(2) received a notice from us instructing you to complete this form for e-folder access. You do not need to
complete the financial portion of the form, or
(3) want to register for direct payment of fees. This form collects information necessary to conform to
Internal Revenue Code sections 6041 and 6045(f), which require us to issue IRS Form 1099-MISC or
1099-NEC to individuals who represent claimants and receive direct payment of $600 or more during a
tax year.

•

Once your initial registration is complete, you will receive a notice containing your Representative
Identification (Rep ID) within 2 to 3 weeks. Use this Rep ID on our representative forms in lieu of your
social security number.

•

If you are currently suspended or disqualified from representing claimants in dealings with us, you may not
register until your suspension has ended or we have reinstated you.

•

You must update your registration by completing a new form if your personal, professional, or business
affiliation information changes. Also, complete a new form for changes that include information related to
disbarments, suspensions, or sanctions.

•

Complete this form and fax it to the Office of Central Operations at 1-877-268-3827. Do not fax more
than one Form SSA-1699 at a time. We will return incomplete or inaccurate forms.

•

For more information, please call 1-800-772-6270 or visit our website at www.ssa.gov/ar. If you are
hearing impaired, call our TTY number at 1-800-325-0778. You may also visit your local
Social Security office.

Section 1 – Personal Identification and Personal Contact information
Complete all fields as applicable. If you have previously registered, do not forget to include your name and
Rep ID.
Section 2 – Attorney Status
Provide information in this section only if you check “Yes” that you are an attorney in good standing and are
admitted to practice law.
Section 3 – Non-Attorney Direct Payment Eligibility
Indicate whether or not you are a non-attorney eligible for direct payment of authorized fees.
Section 4 – Business Information
Complete this section if your business address is different from your mailing address.

Form SSA-1699 (xx-xxxx)
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Section 5 – Employer Information
Complete this section if your work as a representative may be affiliated with a firm or organization. If you work
for more than one firm or organization, complete and attach as many copies of this section as needed. You
will need an Employer Identification Number (EIN) for tax purposes. (If you are working as a sole proprietor
and do not have an EIN, we will use your SSN as the Tax Identification Number (TIN).)
Section 6 – Preferred Payment Method
Complete this section only if you are eligible for direct payment of your authorized fees.
Section 7 – Certification and Attestation
Certify the accuracy of all statements in this section.
Section 8 – Perjury Statement
Sign after completing the form.

Privacy Act Statement - Collection and Use of Personal Information
Sections 206(a) 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 you from serving as an appointed representative.
We will use the information to facilitate direct payment of authorized fees and to meet the reporting
requirements of the law. We may also share your information for the following purposes, called routine uses:
• To a third party, where necessary, information pertaining to the identity of a representative payee or
representative payee applicant, the fact of the person’s application for or service as a representative
payee, and, as necessary, the identity of the beneficiary, to obtain information on employment, sources of
income, criminal justice records, stability of residence, and other information relating to the qualifications
and suitability of representative payees or representative payee applicants to serve as representative
payees, or their use of the benefits paid to them under sections 205(j), 807, or 1631(a) of the Social
Security Act; and
• To student volunteers, individuals working under a personal services contract, and other workers who
technically do not have the status of Federal employees, when they are performing work for SSA, as
authorized by law, and they need access to PII in SSA records in order to perform their assigned
agency functions.
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 Notice (SORN) 60-0222,
entitled Master Representative Payee File as published in the Federal Register (FR) on November 2, 2018, at
83 FR 66339; 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 of our SORNs, is available on our website
at www.ssa.gov/privacy.
Paperwork Reduction Act Statement - This information collection meets the 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 20 minutes to read the instructions, gather the facts, and answer the questions. You may send
comments on our time estimate, not the completed form, to SSA, 6401 Security Boulevard, Baltimore, MD,
21235-6401.

Form SSA-1699 (xx-xxxx)
Destroy Prior Editions
Social Security Administration

Page 3 of 6
OMB No. 0960-0732

REGISTRATION FOR APPOINTED REPRESENTATIVE SERVICES AND
DIRECT PAYMENT
Complete all sections that apply to you. We will return incomplete or inaccurate forms.

Section 1 – Personal Identification and Personal Contact Information
If you are already registered but need to update your registration, enter your Rep ID below:

First Name

Middle Name

Date of Birth (MM DD YYYY)

Last Name

Suffix

Social Security Number

Mailing Address
City
Daytime Phone
Number

State
Fax Number
(optional)

ZIP/ Postal Code Country (if outside the U.S.)
Email address (used for registration and online service
messages).

Check here, if this is the preferred address for receiving notices

Section 2 – Attorney Status
Are you currently in good standing and admitted to practice law before the U.S. Supreme Court; a U.S.
Federal, state, territorial, insular possession, or District of Columbia court; or a member of a state bar if that
membership carries with it the authority to practice law in that state? (Check one of the boxes below.)
Yes

No (do not complete this section)

Provide information for one state, U.S. territory, or U.S. Federal Court in which you currently are in good
standing and have the right to practice law.
Court or Bar

Year admitted (YYYY) Court or Bar License Number (if issued)

Court or Bar

Year admitted (YYYY) Court or Bar License Number (if issued)

Court or Bar

Year admitted (YYYY) Court or Bar License Number (if issued)

Form SSA-1699 (xx-xxxx)

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Rep ID

Section 3 – Non-Attorney Direct Payment Eligibility
Are you a non-attorney eligible for direct payment (EDPNA)?
Yes
No (go to section VII, if you are a non-attorney registering for e-folder access only)

Section 4 – Business Information
Complete this only if your business address is different from your mailing address.
Mailing Address
City
Business Phone
Number

State

ZIP/ Postal Code Country (if outside the U.S.)

Business Fax Number
(optional)

Business Email address (optional)

Check here, if this is the preferred address for receiving notices
I work for a non-profit organization (e.g., law clinic, state legal aid)

Section 5 – Employer Information
Organization’s Name (Enter the full name of the business, entity, firm, or organization)
EIN
Organization’s Address
City
Business Phone
Number

State

ZIP/ Postal Code Country (if outside the U.S.)

Business Fax Number
(optional)

Business Email address (optional)

Check here, if this is the preferred address for receiving notices

Form SSA-1699 (xx-xxxx)

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Rep ID

Section 6 – Preferred Payment Method
Direct Deposit to a U.S. Financial Institution (I confirm that I am the owner or co-owner of this account.)
Type of Financial Account:

Checking

Savings

Routing Number

Account number

Check (Will be mailed to preferred notice address)
Mailing Address for Tax Purposes (This is the address where we will send your Form 1099-MISC
or 1099-NEC)
Same as home address

Same as business address

Same as employer address

Section 7 – Certification and Self-Reporting
•
•
•
•
•
•
•
•

•

I understand and agree that I will comply with SSA’s rules or policies 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 rules or policies, I may be suspended or disqualified
as a representative before SSA, and could be subject to civil monetary penalties or criminally punished by
a fine, imprisonment, or both.
I will not disclose any information that SSA has furnished about a claim or prospective claim to any
unauthorized party without the claimant’s specific written consent unless otherwise authorized or required
to do so by an SSA regulation or other Federal law.
I have reasonable administrative, technical, and physical security safeguards to protect the confidentiality
of all personal information I receive from SSA from loss, theft, or inadvertent disclosure.
I will not omit or otherwise withhold disclosure of information to SSA that is material to the benefit
entitlement or eligibility of claimants or beneficiaries, nor will I cause someone else to do so, if I know or
should know, that this would be false or misleading.
I will not use words, letters, symbols, branding, or emblems in my advertising or other communications in a
way that conveys the false impression that SSA has approved, endorsed, or authorized me, my
communications, or my organization, or that I have some connection with or authorization from SSA.
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 any prior registration not otherwise changed herein, and that they are all currently true and correct
to the best of my knowledge.
I will update this registration if my personal, professional or business affiliation information changes,
including information related to disbarments, suspensions or sanctions.
I certify to all of the above. (Initial)

Form SSA-1699 (xx-xxxx)

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Rep ID

Section 7 – Certification and Self-Reporting (continued)
1.

Have you ever been suspended or prohibited from practice before SSA or
any other Federal program or agency?

2.

Have you ever been disbarred or suspended from a court or bar to which
you were previously admitted to practice as an attorney?

3.

Have you ever been convicted of a violation under Section 206 or 1631(d)
of the Social Security Act?

4.

Have you ever been disqualified from representing a claimant as a
current or former officer or employee of the United States?

Yes (Explain below.)
No
Yes (Explain below.)
No
Yes (Explain below.)
No
Yes (Explain below.)
No

For each Yes answer above, provide the information below regarding that event (Attach copies of this
page if you need more space.)
Disqualifying Agency, Court or Bar Name:

Bar Number (if applicable)

Year admitted to the Bar

Beginning date of disbarment or suspension

Ending date of disbarment or suspension (if ended)

Brief description of circumstances for investigation

Section 8 – Perjury Statement
I agree that a copy of this signed Form SSA-1699 will 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 application and it is true
and correct to the best of my knowledge.
Signature
Date