Form SSA-1695 Identifying Information for Possible Direct Payment of A

Form Approved
OMB No. 0960-0730

Social Security Administration

Identifying Information for Possible Direct Payment of Authorized Fees
Information About the Claimant
First Name

Middle Name

Last Name

Suffix

Wage Earner's Name if different than above

Type of Benefits

Social Security Number

Wage Earner's Social Security Number if different

Title II (RSDI)

Title XVI (SSI)

Information about You, the Representative
Name

Social Security Number

City

P.O. Box, Street, Apt., or Suite No.
State

ZIP Code or Postal Zone

Phone Number (including area code)

Country

Fax Number (optional)

Employer Identification Number (EIN), if applicable. If you are representing the claimant(s) as a partner or
an employee of a firm or other business entity, you may provide the EIN of the firm or business. See instructions
on Page 2 for more information.

Information about Other Claimants You are Representing in Connection with this Claim
List below the Social Security Numbers and names of all other claimants not mentioned above. If all
claimants will not fit on this form, list on a separate form or blank paper.
Claimant's Social Security Number

Claimant's Name

To SSA STAFF: After the information on this form is entered into the appropriate system(s),
immediately shred the form. Under no circumstances should this form be scanned, placed in a claims
file or otherwise retained.
Form SSA-1695 (09-2006)

Page 1

IMPORTANT INFORMATION
Purpose of Form
An attorney or other person who wishes to charge or collect a fee for providing services in connection with a claim before the
Social Security Administration (SSA) must first obtain approval from SSA. The request for appointment is generally made
using the SSA-1696-U4, Appointment of Representative, or equivalent written statement. An attorney or other person who
wishes to receive direct payment of authorized fees from SSA must have completed an SSA-1699, Request for Appointed
Representative's Direct Payment Information, in order to provide the identifying information that will be used to process
these direct payments, including the possible use of direct deposit to a financial institution, and to meet any requirements for
issuance of a Form 1099-MISC. It is important to complete a new SSA-1699 whenever there are changes to identifying
information. In addition, an attorney or other person must complete this SSA-1695, Identifying Information for Possible
Direct Payment of Authorized Fees, for each claim in which a request is being made to receive direct payment of authorized
fees.

Instructions for Completing the Form
Claimant Information--Please provide the Social Security Number (SSN) and name of the claimant that you will represent before SSA.
Wage Earner Information--If the claim is being filed on the Social Security record of someone other than the claimant, please provide
the SSN and name of that wage earner.
Type of Benefits Information--Please specify the type of benefits for which you are representing the claimant(s).
Representative Information--Please enter your SSN and name as shown on your Social Security card and your mailing address. If you
have changed your last name (e.g., due to marriage), please contact your local SSA office to make this change to your Social Security
record. In addition, if you are representing the claimant(s) as a partner or employee of a firm or other business entity, you may provide
the EIN of that entity. This will allow SSA to issue a Form 1099-MISC to that entity to reflect that the direct payment of authorized fees
you receive is actually income to that entity for tax purposes.
Information About Other Claimants--If you are representing other claimants in this claim that are not mentioned above, please provide
their SSNs and names. If there are more than five individuals, please provide this information on a separate attachment to this form.

Privacy Act Notice See Revised Privacy Act Statement
We are required by section 206(a) and 1631(d) of the Social Security Act to ask you to give us the information on this form. The
information is needed to facilitate direct payment of authorized fees and to meet the reporting requirements of the law. Although
responses to the questions are voluntary, failure to provide answers to the questions on this form will result in nonpayment for your
service.
The information obtained on this form is almost never used for any purpose other than that stated above. However, sometimes the law
requires us to disclose the facts on this form without your consent. For example, we must release this information to another person or
government agency if federal law requires that we do so or to contractors, as necessary, to assist SSA in the efficient administration of its
programs.
Explanations about the reasons why information you provide us may be used or given out are available in Social Security offices. If you
want to learn more about this, contact any Social Security office.

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 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, 6401 Security Boulevard, Baltimore, MD, 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.

See Revised Paperwork Reduction Act Statement

Form SSA-1695 (09-2006)

Page 2

The following revised Privacy Act Statement will be inserted into the form
at its next scheduled reprinting:
Privacy Act Statement
Sections 206(a) and 1631(d), of the Social Security Act, as amended, authorizes us to
collect this information. The information is needed to facilitate direct payment of
authorized fees and to meet the reporting requirements of the law. The information you
furnish on this form is voluntary. However, failure to provide all or part of the
information may result in nonpayment for your services.
We rarely use the information you supply for any purpose other than for making a
determination regarding direct payment of fees or to meet the reporting requirements of
the law. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to: (1) to
enable a third party or an agency to assist Social Security in establishing rights to Social
Security benefits and/or coverage; (2) to comply with Federal laws requiring the release
of information from Social Security records (e.g., to the Government Accountability
Office and Department of Veteran Affairs); (3) to make determinations for eligibility in
similar health and income maintenance programs at the Federal, State, and local level; (4)
to the Internal Revenue Service and to state and local government tax agencies in
response to inquiries regarding receipt of fees paid in any calendar year; (5) to employers
to (a) collect debts owed to the Social Security Administration and (b) to carry out the
requirements of sections 6041 and 6045(f) of the Internal Revenue Code; and (6) to
facilitate statistical research, audit or investigative activities necessary to assure the
integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state or local
government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for Federally funded and administered benefit
programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Record
Notice 60-0325. The notices, additional information regarding this form, and information
regarding our programs and systems, are available on-line at
www.socialsecurityadministration.gov or at your local Social Security office.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 OR
BRING 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 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.