Information Collection

Appointment of Representative

IC 9438 under ICR 201308-0960-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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	Form
SSA-1696-U4 Appointment of Representative SSA-1696 Revised Version.pdf	Form
SSA-1696 Current Version.pdf SSA-1696 Current Version	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 410.684 20 CFR 414.1725 20 CFR 416.1507 20 CFR 404.1720 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	Appointment of Representative	SSA-1696 Revised Version.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 800,000

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	800,000	248,480	551,520
Annual IC Time Burden (Hours)	133,333	41,413	91,920
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-1696 Current Version	SSA-1696 Current Version.pdf	09/26/2013

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