Information Collection

Appointment of Representative

IC 9438 under ICR 201610-0960-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Revised PA Statement.pdf	Other-Revised PA Statement
SSA-1696-U4 Appointment of Representative SSA-1696-U4 - Revised.pdf	Form
SSA-1696-U4 - Current.pdf SSA-1696-U4 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-U4 - Revised.pdf		Yes	No	Fillable Printable
Other-Revised PA Statement			Revised PA Statement.pdf		Yes	No	Fillable Printable

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	Previously Approved
Annual Number of Responses for this IC	800,000	800,000
Annual IC Time Burden (Hours)	133,333	133,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-1696-U4 Current Version	SSA-1696-U4 - Current.pdf	12/07/2016

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