Form SSA-1696 Claimant's Appointment of a Representative

Form SSA-1696 (XX-2023) UF
Discontinue Prior Editions

Instructions for Completing Form SSA-1696

Page 1 of 6

Keep a copy of this form for your records
DO NOT FILE Form SSA-1696 if you do not have a claim, you are not filing a claim with this form, or there is no other
case or issue pending decision with us.
In this document, “you” means the claimant, beneficiary, auxiliary or spouse. “We,” “Us” and “SSA” means the Social Security
Administration.
General Information About This Form
• You have the right to 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, visit our website at
www.ssa.gov/representation. To locate your local field office, you can visit our website at www.ssa.gov/locatoror call us, toll-free,
at 1-800-772-1213.
• You and your representative(s) may use this form to start the representation. Your representative may also use this form to
waive a fee, waive direct payment of the fee, or tell us that a third party will pay the fee. Your representative may also give
the fee to an entity, such as business handling disability or a law firm, if the representative is an employee of the entity.
• 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 come to our office, reads to you from documents, or interprets for you if you speak another
language. You only need to appoint someone if that person will be acting on your behalf or appearing before us on your behalf.
• You and your representative(s) must give us accurate information as quickly as possible. Providing misleading or false evidence
on this form or on 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
If you are using this form to appoint a representative, you can complete Sections 1, 3, and 4 as well as your Social Security number
on top of each page. Your representative should complete Sections 2, 5, 6, and 7 and if registered the Representative ID number
on each page. You should each complete Section 8 independently. Your representative or someone else can help you complete
the form, but you must sign and date Section 8. You or your representative must submit the completed form to us before we will
recognize your representative. You can electronically upload it, mail, fax, or eFax it to us or file it in-person at your local field office.
Do not file this form with your local State Disability Determination Services office. If you are appointing multiple representatives, use
separate forms for each representative.
Section 1 - Claimant's Information and Number Holder's Information
Complete all the information, including your Social Security number. If you are filing your claim on someone else's Social
Security record, this person is the “number holder” and we need the number holder’s information to process your claim. Mark
the address box only if your address changed since you filed your application for benefits. If there is no change, leave blank.
Section 2 - Representative's Information
Your representative should complete all the information in this section.
Section 3 - Principal Representative
If you had at any time before, or have now more than one representative, the person you name in this section will now be your
principal representative. We will make contact and send notices to this person. Any principal representative you named before will
no longer be your principal, but that person can still be appointed as your representative. If you want to revoke any previously
appointed representative(s) including your prior principal representative, you must file with us a separate writing that you sign and
date.
Section 4 - Claim Type
In this section, check all types of claims for which you seek representation.
Section 5 - Representative's Status, Affiliations, and Certifications
Your representative must complete this section to let us know the representative’s status as a professional. If your representative
is seeking a fee and is an employee of an entity or firm, the representative should also complete the affiliation section and give us
the Employer Identification Number (EIN). If your representative asks us to pay any fee we authorize to the representative’s
employer, we will send the appropriate tax forms to the entity and the representative. For more information on Forms IRS 1099MISC or -NEC and employer registration, visit our website at www.ssa.gov/representation. Your representative should also certify
the accuracy of all statements in this section. When your representative selects Section 5 Part C to assign any fee we authorize to
an entity, we will pay the entity directly.

Section 6 - Fee Arrangement
This section reflects the claimant’s and representative’s agreement to collect a fee, waive a fee or waive direct payment.
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 any responsibility to pay any fees or expenses.
Section 7 - Other Claimants
If your auxiliary beneficiaries, such as your children, or spouse, have not appointed their own representative(s), list their names and
Social Security numbers in this section.
Section 8 - Signatures
You must sign and date this section. If you sign in a manner other signing your name in ink, we will contact you to verify your
signature, and your intent to make this appointment.
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 your information, which we will use to verify
the appointment of your representative and their acceptance of the appointment. Providing this information is voluntary, but not
providing all or part of the information may prevent us from assisting you with the request. As law permits, we may use and
share the information you submit, including with a congressional office, Federal, State, and local agencies, and others, as
outlined in the routine uses within System of Records Notices (SORN) 60-0089, 60-0320, and 60-0325; available at
www.ssa.gov/privacy. The information you submit may also be used in computer matching programs to establish or verify
eligibility for Federal benefit programs and to recoup debts under these programs.
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.

Form SSA-1696 (XX-2023) UF
Discontinue Prior Editions

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Claimant's Social Security Number

-

OMB No. 0960-0527

Representative's Rep ID

-

Claimant's Appointment of a Representative
Section 1 - Claimant's Information
First Name

Initial Last Name
ZIP P/Postal Code

My address that I provided on my application for benefits has changed since I filed.
Number Holder's Information (Complete only when applicable)

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

-

-

First Name

Initial Last Name

Section 2 - Representative's Information
Representatives who are eligible and seek direct payment of their fee must register and receive a Rep ID. For more information about
registration visit us on-line at www.ssa.gov/ar, contact us at 1-800-772-1213, (TTY 1-800-325-0778) or visit your local Social Security
office.
First Name

Initial

Last Name

Address

City

State

Phone Number

Fax Number (Optional)

Country/Area Code

Phone Number

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

Country/Area Code

Phone Number

Section 3 – Claimant’s Principal Representative (Complete only when applicable)
I have appointed before, or appoint now, more than one representative. The person named below is my principal representative. I
ask SSA to make contacts or send notices to this person. Any principal representative I named before is no longer my principal
representative but may still be appointed as my representative. I understand that if I want to revoke any previously appointed
representative(s) including any other principal representative(s), I must file with SSA a separate writing that I sign and date.

Name: ____________________________________________________________________________

Claimant's Social Security Number

-

Representative's Rep ID

Section 4 - Claim Type

I appoint the individual named in Section 2 to act as my representative in connection with my claim(s) or asserted right(s) under Title
II (RSDI), Title XVI (SSI), Title XVIII (Medicare Coverage), and Title VIII (SVB) of the Social Security Act, as presently amended,
specifically for the issues identified below: (Check all that apply)
Claim/Appeal for Title II Disability Benefits

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

Claim/Appeal for Title XVI Disability Benefits
Claim/Appeal for Title XVI Benefits
Claim/Appeal for Retirement Benefits
Claim/Appeal for Title XVIII (Medicare), VIII (Special
Veteran’s Benefits)

Other _______________________ (E.g., benefit amount,
representative payee, suspension, termination, overpayment.

Section 5 - Representative's Status, Affiliations, and Certifications
Part A - Representative's Status, Disqualifications or Suspensions
(Representatives must always keep this information current)
I am an attorney (SSA rules state that a claimant may appoint an attorney 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.)
I am a non-attorney eligible for direct payment (SSA rules require that non-attorneys meet certain criteria to qualify for
direct payment. See our website at www.ssa.gov/representation for criteria).
I am a non-attorney not eligible for direct payment.
I am now or have previously been (check all that apply):
Disbarred or suspended from a court or bar to which I was previously admitted to practice law.
If selected, explain: _________________________________________________________________________________
Previously been disqualified from participating in or appearing before a Federal program or agency.
If selected, explain: __________________________________________________________________________________
Removed from practice or has/had any or all my licenses suspended by a professional licensing authority or agency.
If selected, explain: __________________________________________________________________________________
Part B – Representative’s 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. (If you do not qualify for or seek direct payment mark no EIN.)
EIN

-

No EIN

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)
Representative's Business Address (if different than mailing address)
City
Country - if outside the U.S.

State

ZIP/Postal Code

Form SSA-1696 (XX-2023) UF
Discontinue Prior Editions

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Claimant's Social Security Number

-

Representative's Rep ID

Part C - Payment of Authorized Fee to an Entity (Complete only when applicable)

I, the representative whose name appears in Section 2 and whose signature appears in Section 8, request any fee
authorized to me for representational services I have provided or will provide in this claim as a salaried employee of the
affiliated entity I have identified above, to be paid to the entity. I understand that the entity to which I give my fee must be
registered prior to direct payment. I also understand that I can withdraw this statement only within a specified timeframe.
Part D – Representative’s Certifications

I accept this appointment and certify the following:
•

I understand and agree that I will comply with the applicable policy and SSA 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 applicable policy and SSA rules I may be suspended or disqualified from
acting 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 disqualified from practicing before the SSA.

•

I am not prohibited 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 1 of this form in connection with the claims and
asserted rights described in Section 4 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 have examined all 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.

I CERTIFY TO ALL OF THE ABOVE

(Representative's Initials)

Section 6 - Fee Arrangement
Check one box below. If the representative is eligible for direct payment and this section is left unchecked, we will assume the
representative will seek a fee, until we receive a written waiver.
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.)
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 the claimant, any auxiliary beneficiaries or any other individual, but a thirdparty entity will pay my fee. 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.)
I waive the right to a fee.

Form SSA-1696 (XX-XXXX) UF

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Claimant's Social Security Number

-

Representative's Rep ID

Section 7 - Other Claimants

List below any unrepresented auxiliary beneficiaries, such as a child or spouse of the claimant or Number Holder named on this
form.
Social Security Number

Name

-

-

-

-

-

-

-

Section 8 - Signatures

Representative's Signature

Date

Claimant's Signature

Date