Information Collection

Appointment of Representative

IC 9438 under ICR 201103-0960-019 · OMB 0960-0527.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0527 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1696-U4 Appointment of Representative Appointment of Representative	Form
SSA-1696-U4 Appointment of Representative SSA-1696 Mock Up Final (4).doc	Form
Current SSA-1696.pdf Current SSA-1696	IC Document
SSA-1696 with minor revisions (3-24-11).doc Minor Website Revision	IC Document

IC Title:

Appointment of Representative

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.1720 20 CFR 410.684 20 CFR 414.1725 20 CFR 416.1507 20 CFR 404.1707

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	SSA-1696-U4				No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 551,520

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	551,520	551,520
Annual IC Time Burden (Hours)	91,920	91,920
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-1696		10/06/2010
Minor Website Revision		03/24/2011

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

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