SSA-1696 (Current Version)

SSA-1696--Current Version.pdf

Appointment of Representative

SSA-1696 (Current Version)

OMB: 0960-0527

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Social Security Administration

Please read the back of the last copy before you complete this form.

Name (Claimant) (Print or Type)

Social Security Number

Wage Earner (If Different)

Social Security Number

Form Approved
OMB No. 0960-0527

APPOINTMENT OF REPRESENTATIVE

Part I

I appoint this person,
(Name and Address)

to act as my representative in connection with my claim(s) or asserted right(s) under:
Title II
Title XVI
Title XVIII
Title VIII
(RSDI)
(SSI)
(Medicare Coverage)
(SVB)
This person may, entirely in my place, make any request or give any notice; give or draw out evidence or
information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s).

I appoint, or I now have, more than one representative. My main representative
is
.
(Name of Principal Representative)

Signature (Claimant)

Address

Telephone Number (with Area Code)

Fax Number (with Area Code)

Part II

Date

ACCEPTANCE OF APPOINTMENT

I,
, hereby accept the above appointment. I certify that I
have not been suspended or prohibited from practice before the Social Security Administration; that I am not
disqualified from representing the claimant as a current or former officer or employee of the United States; and that
I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has been
approved in accordance with the laws and rules referred to on the reverse side of the representative's copy of this
form. If I decide not to charge or collect a fee for the representation, I will notify the Social Security Administration.
(Completion of Part III satisfies this requirement.)

Check one:

I am an attorney.

I am a non-attorney who is eligible to receive direct fee payment.

I am not an attorney and I am ineligible to receive direct fee payment.
I have been disbarred or suspended from a court or bar to which I was previously admitted to practice as an

attorney.

YES
NO

I have been disqualified from participating in or appearing before a Federal program or agency.

YES

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge.
Signature (Representative)

Address

Telephone Number (with Area Code)

Fax Number (with Area Code)

Date

Part III (Optional)
WAIVER OF FEE
I waive my right to charge and collect a fee under sections 206 and 1631(d)(2) of the Social Security Act. I
release my client (the claimant) from any obligations, contractual or otherwise, which may be owed to me for
services I have provided in connection with my client's claim(s) or asserted right(s).
Signature (Representative)
Date
Part IV (Optional)

WAIVER OF DIRECT PAYMENT

by Attorney or Non-Attorney Eligible to Receive Direct Payment
I waive only my right to direct payment of a fee from the withheld past-due retirement, survivors, disability
insurance or supplemental security income benefits of my client (the claimant). I do not waive my right to request
fee approval and to collect a fee directly from my client or a third party.
Signature (Attorney or Eligible Non-Attorney (for Direct Payment) Representative)
Date
Form SSA-1696-U4 (1-2005) EF (1-2005)
Destroy Prior Editions

(See Important Information on Reverse)

FILE COPY

INFORMATION FOR CLAIMANTS
What a Representative May Do
We will work directly with your appointed representative unless
he or she asks us to work directly with you. Your representative
may:
o
o
o
o
o

get information from your claim(s) file;
give us evidence or information to support your claim;
come with you, or for you, to any interview,
conference, or hearing you have with us;
request a reconsideration, hearing, or Appeals Council
review; and
help you and your witnesses prepare for a hearing and
question any witnesses.

Also, your representative will receive a copy of the
decision(s) we make on your claim(s). We will rely on your
representative to tell you about the status of your claim(s), but you
still may call or visit us for information.
You and your representative(s) are responsible for giving Social
Security accurate information. It is wrong to willingly furnish
false information. Doing so may result in criminal prosecution.
We usually continue to work with your representative until
(1) you tell us that he or she no longer represents you; or
(2) your representative tells us that he or she is withdrawing or
indicates that his or her services have ended (for example, by
filing a fee petition or not pursuing an appeal). We do not
continue to work with someone who is suspended or disqualified
from representing claimants.

What Your Representative(s) May Charge
Each representative you appoint can ask for a fee. To charge you
a fee for services, your representative must get our approval.
(Even when someone else will pay the fee for you, for example,
an insurance company, your representative usually must get our
approval.) One way is to file a fee petition. The other way is to
file a fee agreement with us. In either case, your representative
cannot charge you more than the fee amount we approve. If he or
she does, promptly report this to your Social Security office.
o Filing a Fee Petition
Your representative may ask for approval of a fee by giving us a
fee petition when his or her work on your claim(s) is complete.
This written request describes in detail the amount of time he or
she spent on each service provided you. The request also gives
the amount of the fee the representative wants to charge for these
services. Your representative must give you a copy of the fee
petition and each attachment. If you disagree with the information
shown in the fee petition, contact your Social Security office.
Please do this within 20 days of receiving your copy of the
petition.
We will review the petition and consider the reasonable value of
the services provided. Then we will tell you in writing the
amount of the fee we approve.

Form SSA-1696-U4 (1-2005) EF (1-2005)

What Your Representative(s) May Charge,
continued
o Filing A Fee Agreement
If you and your representative have a written fee agreement,
one of you must give it to us before we decide your claim(s).
We usually will approve the agreement if you both signed it;
the fee you agreed on is no more than 25 percent of past-due
benefits, or $5,300 (or a higher amount we set and
announced in the Federal Register), whichever is less; we
approve your claim(s); and your claim results in past-due
benefits. We will tell you in writing the amount of the fee
your representative can charge based on the agreement.
If we do not approve the fee agreement, we will tell you and your
representative in writing. Then your representative must file a fee petition
to charge and collect a fee.
After we tell you the amount of the fee your representative can charge, you
or your representative can ask us to look at it again if either or both of you
disagree with the amount. (If we approved a fee agreement, the person who
decided your claim(s) also may ask us to lower the amount.) Someone who
did not decide the amount of the fee the first time will review and finally
decide the amount of the fee.

How Much You Pay
You never owe more than the fee we approve, except for:
o

any fee a Federal court allows for your representative's

services before it; and

o ut-of-pocket expenses your representative incurs or
expects to incur, for example, the cost of getting your

doctor's or hospital's records. Our approval is not

needed for such expenses.

Your representative may accept money in advance as long as
he or she holds it in a trust or escrow account. If an attorney
or a non-attorney who is eligible to receive direct fee payment
represents you, and if your retirement, survivors, disability
insurance, and/or supplemental security income claim(s)
results in past-due benefits, we usually withhold 25 percent of
your past-due benefits to pay toward the fee for you.
You must pay your representative directly:
o the rest of the fee you owe
-

if the amount of the fee is more than any amount(s)
your representative held for you in a trust or
escrow account and we withheld and paid your
representative for you.

o all of the fee you owe
-

if we did not withhold past-due benefits, for example, because
your representative waived direct payment, or you discharged the
representative, or the representative withdrew from representing
you before we issued a favorable decision; or if we withheld, but
later paid you the money because your representative did not either
ask for our approval until after 60 days of the date of your notice
of award or tell us on time that he or she planned to ask for a fee.

Social Security Administration

Please read the back of the last copy before you complete this form.

Name (Claimant) (Print or Type)

Social Security Number

Wage Earner (If Different)

Social Security Number

Form Approved
OMB No. 0960-0527

APPOINTMENT OF REPRESENTATIVE

Part I

I appoint this person,
(Name and Address)

I appoint, or I now have, more than one representative. My main representative
is
.
(Name of Principal Representative)

Signature (Claimant)

Address

Telephone Number (with Area Code)

Fax Number (with Area Code)

Part II

Date

ACCEPTANCE OF APPOINTMENT

Check one:

I am an attorney.

I am a non-attorney who is eligible to receive direct fee payment.

I am not an attorney and I am ineligible to receive direct fee payment.
I have been disbarred or suspended from a court or bar to which I was previously admitted to practice as an

attorney.

YES
NO

I have been disqualified from participating in or appearing before a Federal program or agency.

YES

Address

Telephone Number (with Area Code)

Fax Number (with Area Code)

Date

WAIVER OF DIRECT PAYMENT

(See Important Information on Reverse)

CLAIMANT'S COPY

INFORMATION FOR CLAIMANTS
What a Representative May Do
We will work directly with your appointed representative unless
he or she asks us to work directly with you. Your representative
may:
o
o
o
o
o

Form SSA-1696-U4 (1-2005) EF (1-2005)

How Much You Pay
You never owe more than the fee we approve, except for:
o

any fee a Federal court allows for your representative's

services before it; and

o ut-of-pocket expenses your representative incurs or
expects to incur, for example, the cost of getting your

doctor's or hospital's records. Our approval is not

needed for such expenses.

if the amount of the fee is more than any amount(s)
your representative held for you in a trust or
escrow account and we withheld and paid your
representative for you.

o all of the fee you owe
-

Social Security Administration

Please read the back of the last copy before you complete this form.

Name (Claimant) (Print or Type)

Social Security Number

Wage Earner (If Different)

Social Security Number

Form Approved
OMB No. 0960-0527

APPOINTMENT OF REPRESENTATIVE

Part I

I appoint this person,
(Name and Address)

I appoint, or I now have, more than one representative. My main representative
is
.
(Name of Principal Representative)

Signature (Claimant)

Address

Telephone Number (with Area Code)

Fax Number (with Area Code)

Part II

Date

ACCEPTANCE OF APPOINTMENT

Check one:

I am an attorney.

I am a non-attorney who is eligible to receive direct fee payment.

I am not an attorney and I am ineligible to receive direct fee payment.
I have been disbarred or suspended from a court or bar to which I was previously admitted to practice as an

attorney.

YES
NO

I have been disqualified from participating in or appearing before a Federal program or agency.

YES

Address

Telephone Number (with Area Code)

Fax Number (with Area Code)

Date

WAIVER OF DIRECT PAYMENT

(See Important Information on Reverse)

REPRESENTATIVE COPY

INFORMATION FOR REPRESENTATIVES

Fees for Representation
An attorney or other person who wants to charge or
collect a fee for providing services in connection with a
claim before the Social Security Administration must first
obtain our approval of the fee for representation. The only
exceptions are if the fee is for services provided:
o
when a nonprofit organization or government
agency will pay the fee and any expenses from
government funds and the claimant incurs no
liability, directly or indirectly, for the cost(s);
o

in an official capacity such as legal guardian,
committee, or similar court-appointed office and
the court has approved the fee in question; or
in representing the claimant before a court of
law. A representative who has provided
services in a claim before both the Social
Security Administration and a court of law may
seek a fee from either or both, but neither
tribunal has the authority to set a fee for
the other.

Obtaining Approval of a Fee
To charge a fee for services, you must use one of two,
mutually exclusive fee approval processes. You must file
either a fee petition or a fee agreement with us. In either
case, you cannot charge more than the fee amount we
approve.
o Fee Petition Process
You may ask for approval of a fee by giving us a fee
petition when you have completed your services to the
claimant. This written request must describe in detail
the amount of time you spent on each service provided and the
amount of the fee you are requesting.
You must give the claimant a copy of the fee petition
and each attachment. The claimant may disagree with
the information shown by contacting a Social Security
office within 20 days of receiving his or her copy of
the fee petition. We will consider the reasonable value
of the services provided, and send you notice of the
amount of the fee you can charge.
o Fee Agreement Process
If you and the claimant have a written fee agreement, either
of you must give it to us before we decide the claim(s). We
usually will approve the agreement if you both signed it; the
fee you agreed on is no more than 25 percent of past-due
benefits, or $5,300 (or a higher amount we set and announce
in the Federal Register), whichever is less; we approve the
claim(s); and the claim results in past-due benefits. We will
send you a copy of the notice we send the claimant telling
him or her the amount of the fee you can charge based on
the agreement.
If we do not approve the fee agreement, we will tell you in
writing. We also will tell you and the claimant that you must file a
fee petition if you wish to charge and collect a fee.
After we tell you the amount of the fee you can charge, you
or the claimant may ask us in writing to review the
approved fee. (If we approved a fee agreement, the person
who decided the claim(s) also may ask us to lower the
amount.) Someone who did not decide the amount of the fee
the first time will review and finally decide the amount of
the fee.
Form SSA-1696-U4 (1-2005) EF (1-2005)

Collecting a Fee
You may accept money in advance, as long as you hold it
in a trust or escrow account. The claimant never owes you more than
the fee we approve, except for:
o any fee a Federal court allows for your services
before it; and
o out-of-pocket expenses you incur or expect to
incur, for example, the cost of getting evidence.
Our approval is not needed for such expenses.
If you are not an attorney and you are ineligible to receive direct
payment, you must collect the approved fee from the claimant. If you are
interested in becoming eligible to receive direct payment, you can find
information on the procedures for becoming eligible for direct payment
on our "Representing Claimants" website:
http://www.ssa.gov/representation/.
If you are an attorney or a non-attorney whom SSA has found eligible to
receive direct payment, we usually withhold 25 percent of any past-due
benefits that result from a favorably decided retirement, survivors,
disability insurance, or supplemental security income claim. Once we
approve a fee, we pay you all or part of the fee from the funds withheld.
We will also charge you the assessment required by section 206(d) and
1631(d)(2)(C) of the Social Security Act. You cannot charge or collect
this expense from the claimant. You must collect from the claimant:
o the rest he or she owes
- if the amount of the fee is more than the

amount of money we withheld and paid you for

the claimant, and any amount you held for

the claimant in a trust or escrow account.

o all of the fee he or she owes
- if we did not withhold past-due benefits, for example,
because there are no past-due benefits, or the claimant
discharged you, or you withdrew from representing the
claimant; or
- if we withheld, but later paid the money to the claimant
because you did not either ask for our approval until after 60
days of the date of the notice of award or tell us on time that
you planned to ask for a fee.

Conflict of Interest and Penalties
For improper acts, you can be suspended or disqualified
from representing anyone before the Social Security
Administration. You also can face criminal prosecution.
Improper acts include:
o If you are or were an officer or employee of the
United States, providing services as a representative
in certain claims against and other matters affecting
the Federal government.
o Knowingly and willingly furnishing false information.
o Charging or collecting an unauthorized fee or too
much for services provided in any claim, including
services before a court that made a favorable decision.

References
o 18 U.S.C. §§ 203, 205, and 207; and 42 U.S.C. §§
406(a), 1320a-6, and 1383(d)(2)
o 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq.
o Social Security Rulings 88-10c, 85-3, 83-27, and 82-39

Social Security Administration

Please read the back of the last copy before you complete this form.

Name (Claimant) (Print or Type)

Social Security Number

Wage Earner (If Different)

Social Security Number

Form Approved
OMB No. 0960-0527

APPOINTMENT OF REPRESENTATIVE

Part I

I appoint this person,
(Name and Address)

I appoint, or I now have, more than one representative. My main representative
is
.
(Name of Principal Representative)

Signature (Claimant)

Address

Telephone Number (with Area Code)

Fax Number (with Area Code)

Part II

Date

ACCEPTANCE OF APPOINTMENT

Check one:

I am an attorney.

I am a non-attorney who is eligible to receive direct fee payment.

I am not an attorney and I am ineligible to receive direct fee payment.
I have been disbarred or suspended from a court or bar to which I was previously admitted to practice as an

attorney.

YES
NO

I have been disqualified from participating in or appearing before a Federal program or agency.

YES

Address

Telephone Number (with Area Code)

Fax Number (with Area Code)

Date

WAIVER OF DIRECT PAYMENT

(See Important Information on Reverse)

OHA COPY

COMPLETING THIS FORM TO APPOINT A REPRESENTATIVE

Choosing to Be Represented

How To Complete This Form, continued

You can choose to have a representative help you when you
do business with Social Security. We will work with your
representative, just as we would with you. It is important that
you select a qualified person because, once appointed, your
representative may act for you in most Social Security
matters. We give more information, and examples of what a
representative may do, on the back of the "Claimant's Copy"
of this form.

Sign your name, but print or type your address, your area
code and telephone number, and the date.

Paperwork and Privacy Act Notice
The Social Security Administration (SSA) will recognize
someone else as your representative if you sign a written
notice appointing that person and, if he or she is not an
attorney, that person signs the notice agreeing to be your
representative. (You can read more about this in our
regulations: 20 CFR §§ 404.1707 and 416.1507.) Giving the
information this form requests is voluntary. Without it
though, we may not work with the person you choose to
represent you.

How to Complete This Form
Please print or type. At the top, show your full name and
your Social Security number. If your claim is based on
another person's work and earnings, also show the ''wage
earner's'' name and Social Security number. If you appoint
more than one person, you may want to complete a form for
each of them.

Part I Appointment of Representative
Give the name and address of the person(s) you are
appointing. You may appoint an attorney or any other
qualified person to represent you. You also may appoint
more than one person, but see ''What Your Representative(s)
May Charge'' on the back of the ''Claimant's Copy'' of this
form. You can appoint one or more persons in a firm,
corporation, or other organization as your representative(s),
but you may not appoint a law firm, legal aid group,
corporation, or organization itself.
Check the block(s) showing the program(s) under which
you have a claim. You may check more than one block.
Check:
o

Title Il (RSDI), if your claim concerns retirement,
survivors, or disability insurance benefits.

Part II Acceptance of Appointment
Each person you appoint (named in part I) completes this
part, preferably in all cases. If the person is not an
attorney, he or she must give his or her name, state that
he or she accepts the appointment, and sign the form.

Part III

(Optional)

Waiver of Fee

Your representative may complete this part if he or she
will not charge any fee for the services provided in this
claim. If you appoint a second representative or
co-counsel who also will not charge a fee, he or she also
should sign this part or give us a separate, written waiver
statement.

Part IV (Optional) Waiver of Direct Payment by an
Attorney or a Non-Attorney Eligible to Receive Direct
Payment
Your representative may complete this part if he or she is an
attorney or a non-attorney who does not want direct
payment of all or part of the approved fee from past-due
retirement, survivors, disability insurance, or supplemental
security income benefits withheld.
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 about 10 minutes to
read the instructions, gather the facts, and answer the
questions. SEND THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. The
office is listed under U. S. Government agencies in your
telephone directory or you may call Social Security at
1-800-772-1213. You may send comments on our time
estimate above to: SSA, 1338 Annex Building, Baltimore,
MD 21235-6401. Send only comments relating to our
time estimate to this address, not the completed form.

References

itle XVI (SSI), if your claim concerns
T
supplemental security income.

18 U.S.C. §§ 203, 205, and 207; and 42 U.S.C. §§
406(a), 1320a-6, and 1383(d)(2)

Title XVIII (Medicare Coverage), if your claim
concerns entitlement to Medicare or enrollment in
the Supplementary Medical Insurance (SMI) plan.

20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq.

Social Security Rulings 88-10c, 85-3, 83-27, and
82-39

If you will have more than one representative, check the
block and give the name of the person you want to be the
main representative.

Form SSA-1696-U4 (1-2005) EF (1-2005)

File Type	application/pdf
File Title	Appointment of Representative
File Modified	2005-02-24
File Created	2005-01-19