Addendum to the Supporting Statement for 0960-0527

Addendum to the Supporting Statement for Form SSA-1696-U4

Appointment of Representative

20 CFR 404.1707, 404.1720, 414.1725, 410.684, and 416.1507

OMB No. 0960-0527

Revision to the Collection Instrument

Background

Form SSA-1696-U4 is used by the claimant to appoint an attorney or non-attorney to provide representation before SSA in Title II and/or Title XVI claims.

Effective January 1, 2007, attorneys and non-attorney representatives eligible for direct fee payment must register in order to receive direct payment from SSA. This form has been revised to include information related to this process. On the enclosed copy of the form, the revised portions have been highlighted in grey.

Section 205 of the Social Security Protection Act (SSPA) provides that SSA may refuse to recognize as an attorney or non-attorney representative, and may disqualify a representative already recognized, any attorney who has been disbarred or suspended from practicing before any court or bar to which he or she was previously admitted to practice as an attorney or who has been disqualified from participating in or appearing before any Federal program or agency. We are modifying Form SSA-1696-U4 to require a representative to state whether he or she has been disbarred or suspended from any court or bar to which he or she was previously admitted and whether he or she has been disqualified from participating in or appearing before any Federal program or agency.

Section 302 of the SSPA of 2004 (SSPA, Public Law 108-203), enacted March 2, 2004, extends the provisions of Section 206(a)(1)(4)(A) of the Act to Section 1631(d)(2), requiring the Commissioner to withhold 25 percent of Title XVI past-due benefits for direct payment of an attorney’s fee. Prior to enactment of the SSPA, withholding from past due benefits applied only to Title II benefits. We are modifying Form SSA-1696-U4 to reflect extension of withholding from past-due benefits to Title XVI.

Section 303 of the SSPA provides for a five-year demonstration project, to be conducted by SSA, under which the direct payment of SSA-approved fees from a claimant’s past due Social Security benefits is extended to certain non-attorney claimant representatives. Prior to enactment of the SSPA, the direct payment of SSA-approved fees was extended only to attorney representatives. We are modifying Form SSA-1696-U4 to reflect the extension of withholding from past-due benefits to non-attorney representatives.

We are also modifying Form SSA-1696-U4 to remove references to the Federal Coal Mine Health and Safety Act of 1969 (black lung benefits) because jurisdiction for these cases has been transferred from the SSA to the Department of Labor.

Upon approval of these revisions, prior editions of the form will be destroyed.

Revisions to Form SSA-1696-U4

Part I

Added a statement allowing claimants to authorize SSA to release claim-related information to associates or entities designated by the claimant’s appointed representative.

Part II

This section was revised to differentiate between participants and non-participants of the direct payment demonstration project for non-attorneys.

Part IV

This section was revised to include language referring to a non-attorney participating in the direct payment project.

The statement “waiving direct payment” was added to the signature line.

INFORMATION FOR CLAIMANTS

Language was added reminding claimants that, with their permission, a representative may designate an associate to receive information from the claimant’s file.

Language was added in reference to the Federal reviewing official (FedRO).

A paragraph on discharging a representative was edited to instruct the claimant that SSA must be informed of this change in writing.

Language was added to further explain the withholding of past due benefits for direct payment. This paragraph also includes information on mandatory registration for direct payment. It also explains that the claimant is responsible for paying the representative if he/she is not registered for direct payment.

COMPLETING THIS FORM TO APPOINT A REPRESENTATIVE

The Privacy Act Notice was revised to include language informing the claimant that with permission, the appointed representative may designate an associate to receive information from the claimant’s file. It also tells the claimant how to grant that permission.

Language was added to inform the claimant of how to discharge one representative and appoint another in his/her stead.

The heading for Part IV was edited to include the same language shown on the form.

INFORMATION FOR REPRESENTATIVES

This section was revised to include information on the mandatory registration for direct fee payment. It also includes language informing non-attorneys who are not participating in the direct payment project that they must collect their fee from the claimant.

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