Information Collection

Form SSA-1699 (interim version)

IC 43720 under ICR 201002-0960-003 · OMB 0960-0732.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0732 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1699 Form SSA-1699 (interim version)	Form and Instruction
SSA-1699 Registration for Appointed Representative Services and D SSA-1699 interim form (OMB No. 0960-0732).doc	Form and Instruction
Form SSA-1699 (Revised).pdf SSA-1699 (version approved September 2009)	IC Document

IC Title:

Form SSA-1699 (interim version)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-1699	Registration for Appointed Representative Services and Direct Payment	SSA-1699 interim form (OMB No. 0960-0732).doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 52,800

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	52,800	0	52,800
Annual IC Time Burden (Hours)	17,600	-8,800	26,400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-1699 (version approved September 2009)	Form SSA-1699 (Revised).pdf	02/03/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.