Addendum to the Supporting Statement - 0527

Addendum to the Supporting Statement for Form SSA-1696

Appointment of Representative

20 CFR 404.1707, 404.1720, 408.1101, 416.1507, and 416.1520

OMB No. 0960-0527

Background

Claimants use Form SSA-1696 to appoint an attorney or non-attorney to provide representation before SSA in Title II, Title XVI, Title VIII, and Title XVIII claims, and other matters. We are combining the SSA-1696 and the SSA-1695 (0960-0730) for efficiency and reduction of paper forms. We are also including two new standardized revocation and withdrawal forms (SSA‑1696-SUP1 and SSA-1696-SUP2), which respondents can submit to us separately. Finally, we are revising and reorganizing the sections of the SSA-1696 to provide a better flow and a logical presentation.

Revisions to the Collection Instruments

• Change #1: We enlarged the fields on the SSA-1696.

Justification #1: We did this to allow more space for the respondents to answer the questions.

• Change #2: We included a new question on the SSA-1696 requiring respondents to include the Rep ID.

Justification #2: We included this in compliance with our RASR (Registration, Appointment Services for Representatives) System, to ensure that the form matches our internal system.

• Change #3: We added questions from the SSA-1695 (0960-0730) to this form, and divided the form into eight sections as follows:

• Section 1 – Claimant’s Information – In this section, we collect the claimant’s SSN, name, and contact information. We also collect the Number holder’s name and SSN, if it should differ from the claimant’s. We enlarged the fields for easier data entry. Formerly, we collected this information in Part I of the SSA-1696.

• Section 2 – Disclosure Statement – In this section, we revised and clarified the language for the disclosure statement. Formerly, we collected this information in Part I of the SSA-1696.

• Section 3 – Principal Representative – In this section, we collect information about the principal representative. We clarified the language and separated the data for better visibility. Formerly, we collected this information in Part I of the SSA-1696.

• Section 4 – Representative’s Information – In this Section, we are collecting the Rep ID, name and contact information of the representative. We enlarged the fields for easier data entry. Formerly, we collected this information in Part II of the SSA‑1696.

• Section 5 – Representative’s Status, Affiliation, and Certifications – We separated this section into several parts:

• Part A: Type of Representative – In this part of the section, we ask questions to help determine the type of representative. We reorganized the information for clarity and better flow. Formerly, we collected this information in Part II of the SSA-1696.

• Part B: Disqualification – In this section, we ask questions to determine if the representative is eligible to be a representative. We reorganized the information for clarity and better flow. Formerly, we collected this information in Part II of the SSA-1696.

• Affiliation – In this section, we are collecting the EIN, name and contact of the representative’s business affiliation. Formerly, we collected this information on the SSA-1695.

• Certification – In this section, we ask the representative to certify their responses. We reorganized the information for clarity and better flow. Formerly, we collected this information in Part II of the SSA-1696.

• Section 6 – Claim Type – In this section, we ask for information about the type of claim the respondent filed. We reorganized the information for clarity and better flow. Formerly, we collected this information in Part I of the SSA-1696.

• Section 7 – Fee Arrangement – In this section, we ask for information about the fee arrangement with the representative. We reorganized the information for clarity and better flow. Formerly, we collected this information in Part II of the SSA-1696.

• Section 8 – Signatures – In this section, we ask for signatures from both the claimant and the representative. We clarified the language and separated the data for better visibility. Formerly, we collected this information in Part I, Part II and Part III of the SSA-1696.

Justification #3: We decided to include the information that appears on the SSA-1695 (0960-0730), as part of our effort to combine the two forms and eliminate paperwork for the public. In addition, we clarified the language on the form in accordance with the Plain Language Act. Finally, we reorganized the form to make it easier for respondents to complete the information in a logical manner.

• Change #4: We included the new, supplementary form, SSA-1696-SUP1, Claimant’s Revocation of the Appointment of a Representative.

Justification #4: We included this new form to allow claimants to revoke the appointment of a representative. This new form standardizes the way we collect this information, as previously we had no standard form to collect this information.

• Change #5: We included the new, supplementary form, SSA-1696-SUP2, Representative’s Withdrawal of Acceptance of an Appointment.

Justification #5: We included this new form to allow representative to withdraw from acceptance of an appointment. This new form standardizes the way we collect this information, as previously we had no standard form to collect this information.

• Change #6: We are revising all three forms (SSA-1696, SSA-1696-SUP1, and SSA‑1696‑SUP2) based on the suggestions we received from the National Organization of Social Security Claimants Representatives (NOSSCR).

Justification #6: We made all the suggested revisions we summarized in #8 of the Supporting Statement, as we agreed with NOSSCR’s suggestions and requested changes to the forms.

• Change #7: We are revising the PRA statement on this form.

Justification #7: We are revising the PRA statement to reflect our current boilerplate language.  The current language, which dates back to the last reprint of the form, is now outdated.

• Change #8: We are revising the Privacy Act Statement on this form.

Justification #8: SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the form.

SSA will implement these revisions upon OMB approval.

Revisions to the Public Reporting Burden for this Information Collection

The above listed revisions to the information collection (the addition of questions to the SSA‑1696 and the addition of the two supplemental forms) will increase the overall burden for this collection. The following chart shows the new burden information:

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)
SSA-1696-U4	800,000	1	12	160,000
SSA-1696-SUP1	21,000	1	5	1,750
SSA-1696-SUP2	233,000	1	5	19,417
Totals	1,054,000			181,167

Future Plans: Once OMB approves the above revisions to the SSA-1696, we intend to discontinue the SSA-1695 (0960-0730). We will submit the Discontinuation to OMB once we implement the new version of the SSA-1696.