Information Collection

Appointment of Representative - SSA-1696

IC 9438 under ICR 201805-0960-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Appointment of Representative - SSA-1696	Form and Instruction
SSA-1696 - Revised PA Statement.pdf	Other-Revised PA Statement
SSA-1696 Appointment of Representative SSA-1696 - Revised Version.pdf www.ssa.gov	Form and Instruction
SSA-1696 - Current Version.pdf SSA-1696-U4 Current Version	IC Document
SSA-1695 - Current Version (0960-0730).pdf Current SSA-1695 (0960-0730)	IC Document

IC Title:

Appointment of Representative - SSA-1696

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 and Instruction	SSA-1696	Appointment of Representative	SSA-1696 - Revised Version.pdf	www.ssa.gov	Yes	No	Fillable Printable
Other-Revised PA Statement			SSA-1696 - Revised PA Statement.pdf		Yes	No	Printable 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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	800,000	0	800,000
Annual IC Time Burden (Hours)	160,000	26,667	133,333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-1696-U4 Current Version	SSA-1696 - Current Version.pdf	03/01/2019
Current SSA-1695 (0960-0730)	SSA-1695 - Current Version (0960-0730).pdf	03/01/2019

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