Current SSA-1696

COMPLETING THIS FORM TO APPOINT A REPRESENTATIVE
Choosing To Be Represented

•

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.

If your representative has your permission to designate an
associate, such as a clerk, other party, or entity, such as a
copying service, to receive information for him or her from
us about your claim(s), check the block to authorize this
release.

Privacy Act Notice
Sections 206(a) and 1631(d) of the Social Security Act
authorize the collection of information on this form.
Providing the information is voluntary. However, if you
want to appoint someone to act on your behalf in matters
before the Social Security Administration, then you and that
individual must complete the appropriate sections of this
form. The information is needed to verify your appointment
of the individual as your representative and his/her
acceptance of the appointment.
We may provide information collected on this form to
another Federal, State, or local government agency to assist
us in verifying any information you provide, or if a Federal
law requires the release of information. We may also use the
information you give us when we match records with those
of other Federal, State, or local government agencies. The
law allows us to do this even if you do not agree to it.
With your permission, your representative may designate an
associate or other party to request and receive information
from your claim file on your representative's behalf.
Information about these and other reasons why any
information you provide us may be used or given out is
available in any Social Security office. If you want to
learn more about this, contact any Social Security office.

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:
• Title II (RSDI), if your claim concerns retirement,
survivors, or disability insurance benefits.
• Title XVI (SSI), if your claim concerns
supplemental security income.
Form SSA-1696-U4 (06-2009) ef (06-2009)

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

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.
Sign your name, but print or type your address, your area
code and telephone number, and the date.
If you are appointing a representative to replace a
representative you discharged or who withdrew from
representing you, you must notify us in writing that the prior
appointment has ended.

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 Participating in the Direct
Payment Project
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 clearance 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 (TTY 1-800-325-0778).
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.

References
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18 U.S.C. §§203, 205, and 207; and 42 U.S.C. §§
406(a), 1320a-6, and 1383(d)(2)
20 CFR §§404.1700 et. seq. and 416.1500 et. seq.
Social Security Rulings 88-10c, 85-3, 83-27, and 82-39
26 U.S.C. §§ 6041 and 6045(f)

INFORMATION FOR REPRESENTATIVES
Fees For Representation

Collecting A Fee

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:
• 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);

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:

•

in an official capacity such as legal guardian,
committee, or similar court-appointed office and
the court has approved the fee in question; or

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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.
•

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.

•

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out-of-pocket expenses you incur or expect to
incur, for example, the cost of getting evidence.
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:
•
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.
•

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.
•

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 $6,000 (or a higher
amount we set and announced 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 (06-2009) ef (06-2009)

any fee a Federal court allows for your services
before it; and

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:
• 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.
•

Knowingly and willingly furnishing false information.

•

Charging or collecting an unauthorized fee or too
much for services provided in any claim, including
services before a court which made a favorable
decision.

References
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•
•
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18 U.S.C. §§203, 205, and 207; and 42 U.S.C.
§§406(a), 1320a-6, and 1383(d)(2)
20 CFR §§404.1700 et. seq. and 416.1500 et. seq.
Social Security Rulings 88-10c, 85-3, 83-27, and 82-39
26 U.S.C. §§ 6041 and 6045(f)

INFORMATION FOR CLAIMANTS
What Your Representative(s) May Charge,
continued

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:
•
•

•
•
•

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get information from your claim(s) file;
with your permission, designate associates who perform
administrative duties (e.g. clerks), partners and/or parties
under contractual arrangements (e.g., copying services) to
receive information from us on his or her behalf: By signing
this form, you are providing your permission for your
representative to designate such associates, partners, and/or
contractual parties,
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.

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.

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 knowingly and
willingly furnish false information. Doing so may result in
criminal prosecution.

How Much You Pay
You never owe more than the fee we approve, except for:
• any fee a Federal court allows for your representative's
services before it; and
• out-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.

We usually continue to work with your representative until
(1) you notify us in writing 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.
•

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 (06-2009) ef (06-2009)

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 $6,000
(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.

Your representative may accept money in advance as long as he
or she holds it in a trust or escrow account. We usually withhold
25 percent of your past-due benefits to pay toward the fee for you
if :
•
your retirement, survivors, disabilty insurance, and/or
supplemental security income claim(s) results in past-due
benefits;
•
your representative is an attorney or a non-attorney
participating in the direct fee payment project; and
• your representative registers with us for direct payment
before we effectuate a favorable decision on your claim.
You must pay your representative directly:
•

•

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.
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

Form Approved
OMB No. 0960-0527

Please read the instructions before completing this form.
Name (Claimant) (Print or Type)

Social Security Number

Wage Earner (If Different)

Social Security Number

Part I
I appoint this person,

-

-

-

-

APPOINTMENT OF REPRESENTATIVE

,

(Name and Address)

to act as my representative in connection with my claim(s) or asserted right(s) under:
Title VIII
Title II
Title XVI
Title XVIII
(SVB)
(Medicare Coverage)
(RSDI)
(SSI)
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 authorize the Social Security Administration to release information about my pending claim(s) or asserted
right(s) to designated associates who perform administrative duties (e.g. clerks), partners, and/or parties
under contractual arrangements (e.g. copying services) for or with my representative.
I appoint, or I now have, more than one representative. My main representative
is
.
(Name of Principal Representative)

Address

Signature (Claimant)

Fax Number (with Area Code)

Telephone Number (with Area Code)

(

)

-

Part II

(

)

Date

-

ACCEPTANCE OF APPOINTMENT

, hereby accept the above appointment. I certify that I
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 participating in the direct fee payment
demonstration project.
I am a non-attorney . I am not participating in the direct fee payment demonstration project.
I have been disbarred or suspended from a court or bar to which I was previously admitted to practice as an
attorney.
No
Yes

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

Yes

No

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)

(

)

-

(
)
WAIVER OF FEE

Date

-

Part III (Optional)
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).
Date

Signature (Representative)
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 (Representative Waiving Direct Payment)
Form SSA-1696-U4 (06-2009) ef (06-2009)
Destroy Prior Editions

Date

TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS
(4 Copies: File, Claimant, Representative, ODAR