Form SSA-1699 Registration of Individual for Appointed Representative

REGISTRATION OF INDIVIDUALS AND STAFF FOR
APPOINTED REPRESENTATIVE SERVICES
General Information and Instructions


You can register online at www.socialsecurity.gov/ (URL is TBD) or you can complete this paper form and mail it to
your local Social Security office.



Use this form for initial registration and to make subsequent updates to your information.



If you are currently suspended or disqualified from representing claimants in dealings with SSA, you may not register
(either as a representative or an individual performing services on behalf of a representative) until your suspension
has ended or SSA has reinstated you.



Please read the instructions carefully. The form provides instructions to guide you to the sections and items you must
complete.



We will return incomplete or inaccurate forms.



For more information about the registration process, please visit our website at www.socialsecurity.gov/ (URL is TBD)

Purpose of Form
We use this form to register:





Individuals appointed as representatives;
Individuals who will perform advocacy services on behalf of an appointed entity representative;
Individuals who will act on behalf of an appointed representative (including staff of attorneys and non-attorneys
eligible for direct pay) and want access to our electronic services; and
Individuals who will be responsible for maintaining and updating an entity representative’s registration and
employee information.

All individuals listed above must register with the agency. With this form, we collect personal and other information
necessary to authenticate and authorize you to do business with us and to permit access to our records while protecting
your confidentiality and that of our claimants. We also collect all information necessary to conform to Internal Revenue
Code sections 6041 and 6045(f), which require us to issue IRS Form 1099-MISC to individuals who and affiliated
businesses that represent claimants and receive direct payment of $600 or more during a tax year. Once registration is
complete, you will be issued a User Identification Number (User ID) and Representative Identification Number (Rep ID).

Explanation of terms for completing this form


Advocacy Services—professional activities performed by an individual representative or by an individual working
on behalf of an entity representative on a claim before us. They include, but are not limited to, interpreting agency
law and policy, providing advice to claimants about agency law and policy, presenting evidence, appearing at
hearings, examining witnesses, or signing pleadings and briefs.



Entity—any business, firm, or other association, including but not limited to partnerships, corporations, for-profit
organizations, and not-for-profits organizations that may be appointed as a representative.



On behalf of -- An individual works on behalf of a representative when the individual is not the appointed
representative on a claim, but performs representational services on the claim for the appointed representative. In
sections I-VIII of this form (excluding any supplements to this form), the phrase working "for" a representative has
the same meaning as working "on behalf of" a representative.



Representative—an attorney, an individual other than an attorney, or an entity that meets all of our requirements
and is appointed to represent claimants in dealings with us. For purposes of our rules of conduct and standards
of responsibility, as well as our sanction procedures, representative also includes an attorney or a non-attorney
who is not appointed as a representative but who provides advocacy services by or on behalf of an appointed
representative on a claim before us.



Representational Services—all services that are provided to a claimant in connection with any claim, any
asserted right the claimant may have for an initial or reconsidered determination, and any decision or action by an
ALJ or the Appeals Council.

Form SSA-1699

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

Representative Identification Number (Rep ID)—the number a representative or individual working on behalf of
a representative must use to do business with us either electronically or on paper. We will use this Rep ID in lieu
of an SSN.



User Identification Number (User ID)—the number you must use to access our online services.

Form SSA-1699

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Privacy Act Statement
Collection and Use of Personal Information
Sections 206(a) and 1631(d) of the Social Security Act, as amended, authorize us to collect this information. The
information you provide will be used 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 the requested information will prevent
you from serving as an appointed representative.
We generally use the information you supply for the purpose of facilitating payments. 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 the following:
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 Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, state,
and local level; and
4. To facilitate statistical research, audit or investigative activities necessary to ensure 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 or administered benefit programs and for
repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our programs and systems, is available on-line
at www.socialsecurity.gov or at your local 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 30 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
SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. Local office addresses can be found
on www.socialsecurity.gov or you may call Social Security at 1-800-772-1213. If you are deaf or hard of hearing call our
TTY number at 1-800-325-0778.

Form SSA-1699

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DRAFT

Social Security Administration
OMB No. 0000-0732

REGISTRATION OF INDIVIDUALS AND STAFF FOR
APPOINTED REPRESENTATIVE SERVICES
Indicate whether this is a first-time registration or an update to your previous registration.

 Initial Registration

 Update of Prior Registration

(Complete all sections as instructed.)

Provide your name and Rep ID on this page, update all
information that has changed and, where needed, check the box
to indicate if the information provided is an update, addition,
deletion or cancellation. You must re-attest, sign, and date the
updated form.
Rep ID

Complete all sections that apply to you. We will return incomplete or inaccurate forms.
Section I: Your Personal Identification and Home Contact Information


All individuals initially registering must fill out this section. All fields are required unless indicated as optional.



For your protection, we collect your home contact information to check against our records.



Enter your name in the boxes below exactly as it appears on your Social Security card.



If you want to use a different name, contact your local Social Security office to change the name currently in your
records. You must either receive a new card or receive confirmation that we processed your name change prior to
completing this form.

 Name Changed
First Name

Middle Name

Suffix (if any)

Last Name

Date of Birth (MM/DD/YYYY)
/

Social Security Number
_
_

/

Home Mailing Address
Street Line 1
Line 2
City

State

Zip/Postal Code

Country (if outside the U.S.)

Daytime Telephone Number
__________
_________________ ________

Home Fax Number (Optional)
__________
_________________

Country/Area Code

Country/Area Code

Phone Number

Extension

Phone Number

Home Email Address (Optional - Used for registration purposes and SSA Online service messages.)

Form SSA-1699

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Section II: Your Representational Standing
Check the appropriate box below to indicate your standing:



1. Attorney


You currently are 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 are a member of a state bar if that
membership carries with it the authority to practice law in that state.



If you are not currently admitted and in good standing in at least one jurisdiction, you must register as a nonattorney.
(If you check this standing, go to Section III)

2. Non-Attorney/Staff who provide services to SSA claimants or beneficiaries either as an appointed representative
or on behalf of an appointed representative.
(We collect additional information in Sections IV and V for non-attorneys eligible for direct pay.)



a. You are not an attorney.
(If you check this standing, skip Section III and go to Section IV)



b. You were an attorney, but are not in good standing in at least one jurisdiction.
(If you check this standing, go to Section III)



3. Other (e.g. family member, friend, clergy, etc.)
You are not in the business of providing services to SSA claimants and beneficiaries, but are registering to be an
appointed representative for someone such as a relative, friend, or other acquaintance.
(If you check this standing, complete a. and b. below.)
a.

Address for Receipt of SSA Notices

Same as  Home Address in Section I

Street Line 1
Line 2
City

State

Zip/Postal Code

Country (if outside the U.S.)

b.

Alternate Telephone Number (If different from that provided in Section I.)
__________
_________________ ________
Country/Area Code

Phone Number

Extension

(If you completed #3, skip Sections III, IV, V and VI and go directly to Section VII.)

Form SSA-1699

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Section III: Your Bar and Court Information

 Not an ABA member

1.

American Bar Association (ABA) Number:

2.

Provide the following information for all U.S. courts and bars (state and all Federal levels) to which you are now or
ever have been admitted to practice as an attorney.
Attach additional copies of this page if you have been admitted in more jurisdictions.
U.S. Court or Bar

Code

Year
Admitted
(YYYY)

Court or Bar License Number
(If one issued)

Present Standing

Code

Present Standing
Code
(From chart below)

Present Standing

01

Active (have the right to practice law) and in good standing

11

Not Eligible

02

Inactive (do not currently have the right to practice law) and in good
standing

12

Not Established

03

Suspended

13

Retired

04

Disbarred

14

Emeritus

05

Revoked

15

Incapacity/Disability

06

Surrendered

16

Probation

07

Lapsed

17

Partially Probated Suspension

08

Resigned (voluntary withdrawal), with disciplinary action pending

18

Age Exempt

09

Resigned (voluntary withdrawal) with no disciplinary action pending

19

Other

10

Pending

Form SSA-1699

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Section IV: Your Information as an Individual Representative





If you now or in the future expect to be an appointed representative, complete this section.
If you want us to send notices to different addresses for different claims, attach additional copies of this page.
If, when updating your information, you want to add or delete multiple notice addresses, you must submit a separate
page for each change. If you are deleting a notice address which you previously provided, you must enter it exactly
as you entered it originally.

1.

Are you now or do you expect to ever be appointed as a
representative personally (not work for an entity/firm)?

2.

Address for Receipt of SSA Notices

 Yes (Continue this section.)
 No (Go to Section V)

 Same as Home Address in Section I

 Add  Delete

Street Line 1
Line 2
City

State

Zip/Postal Code

Country (if outside the U.S.)

3.

Business Telephone Number (if different from that
provided in Section I.)
__________
_________________ ________
Country/Area Code

Phone Number

Business Fax Number (Optional)
__________
_________________
Country/Area Code

Phone Number

Extension

4.

Business Email Address (Optional)

5.

Are you currently a non-attorney eligible for direct pay? (You received notice
that you meet our requirements under the Social Security Act or regulations.)

Form SSA-1699

 Yes  No

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SECTION V: Your Information When You Are Working for an Entity or Firm
Complete this section if you will ever perform work for an entity which is appointed as a representative. If you work for
more than one entity, complete and attach as many copies of this section as needed. You will need the entity’s EIN in
order to complete this section.

 Update

Complete 1 through 3 below.
1.

Entity’s Employer Identification Number (EIN)
(See your W-2 or contact the entity/firm to get this number.)

2.

Are you a non-attorney eligible for direct pay?

3.

Provide your contact information when you work for this entity.
(Do not include the name of the entity. We will automatically add the entity name on correspondence.)

_

 Yes  No

Street Line 1
Line 2
City

State

Zip/Postal Code

Country (if outside the U.S.)

Your Telephone Number at this Entity/Firm
__________
________________
__________
Country/Area Code

Phone Number

Extension

Your Fax Number at this Entity/Firm (Optional)
__________
_________________
Country/Area Code
Phone Number

Your Email Address at this Entity/Firm: (Optional)

Attestation by Attorney or Non-Attorney Eligible for Direct Pay


This attestation is required if you work on behalf of an entity that may request direct payment of its fee, and you are
an attorney or a non-attorney eligible for direct pay while working on behalf of this entity.



You only need to make this attestation once, regardless of the number of entities you identify in this section.

Read the statements below and check the box to indicate your certification.
In any claim on which I will not be individually appointed as the representative, but will perform advocacy services
on behalf of an entity that is appointed as a representative:

 All of the advocacy services I will perform on these claims will be on behalf of the entity,
 SSA should pay directly to the entity all fees for the services I will provide on these claims, and
 I will receive my compensation for providing these services directly from the entity.

 I attest to all of the above.

Form SSA-1699

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Section VI: Your Information When You Are Working for an Individual
Complete this section if you will ever perform work for an individual who is appointed as a representative. Before you
register, any individual for whom you work must register with us and receive his or her Rep ID. You will need to ask the
individual for the Rep ID and the name he or she used when registering with us. If you work for more than one individual,
complete and attach as many copies of this section as needed.
Complete items 1 through 3 below.
 Update
1.

Name of Individual for whom you work: This must match the name this individual used when he or she registered
with us.
First Name
Middle Name

Suffix (if any)

Last Name
2.

Rep ID for the individual named above

3.

Provide your contact information when you work for this individual. We will use this information if we need to
reach you regarding any case for which this individual is appointed as the representative.
Street Line 1
Line 2
City

State

Zip/Postal Code

Country (if outside the U.S.)

Your Telephone Number
__________
________________
Country/Area Code

Phone Number

__________
Extension

Your Fax Number (Optional)
__________
_________________
Country/Area Code
Phone Number

Your Email Address: (Optional)

Form SSA-1699

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Section VII: Attestations for Representation
If you will ever be appointed as a representative or will provide advocacy services on behalf of an entity representative,
you MUST ATTEST to these statements and provide any additional information as indicated.
1.
I understand and will comply with SSA laws and rules relating to 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 will not threaten, coerce, intimidate, deceive, or knowingly mislead a claimant or prospective claimant, or
beneficiary, regarding benefits or other rights under the Social Security Act.
I will not knowingly make or present, or participate in making or presenting, false or misleading oral or written
statements, assertions, or representations about a material fact or law concerning a matter within SSA’s jurisdiction.
I am aware that if I fail to comply with any SSA laws and rules relating to representation, I may be suspended or
disqualified from practicing as a representative before SSA.

 I attest to all of the above.
2.

Are you currently or have you ever been:

a.

Suspended or prohibited from practice before SSA or any other Federal program or
agency?

b.

Disbarred or suspended from a court or bar to which you were previously admitted to
practice as an attorney?

c.

Convicted of a violation under Section 206(a) or 1631(d) of the Social Security Act?

d.

Disqualified from representing a claimant as a current or former officer or employee of
the United States?

3.

For each Yes answer in 2, provide the information below (Attach copies of this page if you need more space.)

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

Federal Program or Agency; or
Court or Bar Name:
Describe the Restriction(s) Identified in 2a-2d:
Beginning Date:

Ending Date: (if ended)

Brief Description of Circumstances:

Form SSA-1699

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Section VIII: General Attestations
Everyone registering MUST ATTEST to these statements.
I will not divulge any information that SSA has furnished or disclosed about a claim or prospective claim, unless I
have the claimant’s consent or there is a Federal law or regulation authorizing me to divulge this information.
I have in place reasonable administrative, technical, and physical security safeguards to protect the confidentiality
of all personal information I receive from SSA, to avoid its 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 Social Security program 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 will update this registration if my personal, professional or business affiliation information changes, including
information related to disbarments, suspensions or sanctions.
I am aware that if I fail to comply with SSA laws and rules, I could be criminally punished by a fine or imprisonment
or both, and I could be subject to civil monetary penalties.
I understand that SSA will validate the information I provide.

 I attest to all of the above.
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 of Person Identified in Section I (You must sign your OWN name.)

Form SSA-1699

Date

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Form SSA-1699

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INFORMATION FOR ATTORNEYS AND NON-ATTORNEYS WHO ARE NOT WORKING FOR AN ENTITY/ FIRM
SUPPLEMENT TO: REGISTRATION OF INDIVIDUAL FOR APPOINTED REPRESENTATIVE SERVICES



You must complete item 1 if you are an attorney or a non-attorney eligible for direct pay. If you might request
direct payment for your representational services, you must also complete items 2 and 3 below.



Any information you list below will replace the information which you provided in the past. Tax Address information
will be used to mail IRS Form 1099-MISC if we make direct payments to you as an individual representative.

1.

Address for Receipt of SSA Notice

Same as  Home Address in Section I

Street Line 1
Line 2
City

State

Zip/Postal Code

Country (if outside the U.S.)

2.

What is your preferred payment method?



Direct Deposit to U.S. Bank



I am the owner or co-owner of this account. (You must be the owner or co-owner of the account.)

Type of Financial Account:

 Checking  Savings

Routing Number



Check – Will be mailed to the Notice Address

3.

Your Tax Address

Account Number

Same as  Home Address

 Notice Address in 1 above

Street Line 1
Line 2
City

State

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

Form SSA-1699

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Form SSA-1699

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INFORMATION FOR ATTORNEYS AND NON-ATTORNEYS WHO ARE WORKING FOR
AN ENTITY/ FIRM
SUPPLEMENT TO: REGISTRATION OF INDIVIDUAL FOR APPOINTED REPRESENTATIVE SERVICES






We need this information to send notices and make direct payments to attorneys and non-attorneys eligible for direct
pay who are appointed as individual representatives and are working for an entity/firm until our regulations recognize
entity/firm representatives.
You must complete Section I and Section II (items 1 and 2). If you might request direct payment for your
representational services, you must also complete items 3 and 4 in Section II.
Complete this information for each entity/firm you listed in Section V of the full form SSA-1699.
If you work for additional entities/firms, complete and attach as many copies of this page as you need.

Section I: Your Personal Identification and Contact Information
First Name

Middle Name

Last Name

Suffix

Social Security Number
_
_

Section II: Your Notice and Payment Information when working for this Entity/Firm
1.
2.

Entity’s Employer Identification No. (EIN)
(As listed in Section V of the full form SSA-1699)
Address for Receipt of SSA Notice

_
Same as:  Home Address Section I

Street Line 1
Line 2
City

State

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

3.



What is your preferred payment method?
Direct Deposit to U.S. Bank

 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 the Notice Address.

Form SSA-1699

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Section II: Your Notice and Payment Information when working for this Entity/Firm (Continued)
4.

Your Tax Address

Same as  Home Address in Section I  Notice Address in 2 above

Street Line 1
Line 2
City

State

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

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 supplemental statement and it is
true and correct to the best of my knowledge.
Signature
Date

Form SSA-1699

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