Form SSA-1695 Identifying Information for Possible Direct Payment of A

Form Approved
OMB No. 0960-0730

Social Security Administration

Identifying Information for
Possible Direct Payment of Authorized Fees
Information About the Claimant
First Name

Middle Name

Last Name

Suffix

Wage Earner's Name (if different than above)

Type of Benefits

Social Security Number
_
_
Wage Earner's Social Security Number (if different)
_
_

Title II (RSDI)

Title XVI (SSI)

Information about You, the Representative
Name

Social Security Number
_

P.O. Box, Street, Apt.,or Suite No.

City

State

Country

ZIP Code or Postal Zone

Phone Number (including area code)

_

Fax Number (optional)

Employer Identification Number (EIN), if applicable. If you are representing the claimant(s) as a partner or an employee
of a firm or other business entity, you may provide the EIN of the firm or business. See instructions on Page 2 for more
information.

Information about Other Claimants You are Representing in Connection with this Claim
List below the Social Security Numbers and names of all other claimants not mentioned above. If all claimants will not fit
on this form, list on a separate form or blank paper.
Claimant's Social Security Number
_

_

_

_

_

_

_

_

_

_

Form SSA-1695-F3 (07-2013)
Destroy Prior Editions

Claimant's Name

Page 1

IMPORTANT INFORMATION
Purpose of Form
An attorney or other person who wishes to charge or collect a fee for providing services in connection with a
claim before the Social Security Administration (SSA) must first obtain approval from SSA. The request for
appointment is generally made using the SSA-1696-U4, Appointment of Representative, or equivalent written
statement. An attorney or other person who wishes to receive direct payment of authorized fees from SSA
must have completed an SSA-1699, Registration for Appointed Representative Services and Direct Payment,
in order to provide the identifying information that will be used to process these direct payments, including the
possible use of direct deposit to a financial institution, and to meet any requirements for issuance of a Form
1099-MISC. It is important to complete a new SSA-1699 whenever there are changes to identifying
information. In addition, an attorney or other person must complete this SSA-1695, Identifying Information for
Possible Direct Payment of Authorized Fees, for each claim in which a request is being made to receive direct
payment of authorized fees.

Instructions for Completing the Form
Claimant Information - Please provide the Social Security Number (SSN) and name of the claimant that you
will represent before SSA.
Wage Earner Information - If the claim is being filed on the Social Security record of someone other than the
claimant, please provide the SSN and name of that wage earner.
Type of Benefits Information - Please specify the type of benefits for which you are representing the
claimant(s). Representative Information - Please enter your SSN and name as shown on your Social
Security card and your mailing address. If you have changed your last name (e.g., due to marriage), please
contact your local SSA office to make this change to your Social Security record. In addition, if you are
representing the claimant(s) as a partner or employee of a firm or other business entity, you may provide the
EIN of that entity. This will allow SSA to issue a Form 1099-MISC to that entity to reflect that the direct
payment of authorized fees you receive is actually income to that entity for tax purposes.
Information About Other Claimants - If you are representing other claimants in this claim that are not
mentioned above, please provide their SSNs and names. If there are more than five individuals, please
provide this information on a separate attachment to this form.

Form SSA-1695-F3 (07-2013)

Page 2

Privacy Act Statement
Collection and Use of Personal Information

Sections 206(a) and 1631(d) of the Social Security Act, as amended, authorize us to collect the information on
this form. We will use the information you provide to facilitate direct payment of authorized fees and to meet
the reporting requirements of the law.
Your response is voluntary. However, failing to provide us with all or part of the information could result in
nonpayment for your service.
We rarely use the information you provide for any purpose other than for determining continuing eligibility.
In accordance with 5 U.S.C. § 552a(b) of the Privacy Act, however, we may disclose the information provided
on this form in accordance with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office and Department of Veterans' Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs
at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Computer matching programs
compare our records with those of other Federal, State, or local government agencies. We can use
information from these matching programs to establish or verify a person's eligibility for federally-funded or
administered benefit programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of Records Notices entitled,
Attorney Fee File, 60-0003 and Master Representative Payee File, 60-0222. These notices, additional
information regarding this form, and information regarding our programs and systems, are available on-line at
http://www.socialsecurity.gov or at your local Social Security office.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C.
§ 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these
questions unless we display a valid Office of Management and Budget control number. We estimate that it will
take about 10 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING
THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social
Security office through SSA's website at www.socialsecurity.gov. Offices are also listed under U.S.
Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY
1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.

Form SSA-1695-F3 (07-2013)

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