Information Collection

Form SSA-1699

IC 43720 under ICR 201903-0960-007 · OMB 0960-0732.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0732 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1699 Form SSA-1699	Form and Instruction
Revised PA Statement.pdf	Other-Revised PA Statement
SSA-1699 Registration for Appointed Representative Services and D SSA-1699 - Revised.pdf	Form and Instruction
SSA-1699 - Current.pdf SSA-1699 - Current	IC Document

IC Title:

Form SSA-1699

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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-1699	Registration for Appointed Representative Services and Direct Payment	SSA-1699 - Revised.pdf		No		Fillable Printable
Other-Revised PA Statement			Revised PA Statement.pdf		No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 17,700

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

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	17,700	1,700	16,000
Annual IC Time Burden (Hours)	5,900	567	5,333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-1699 - Current	SSA-1699 - Current.pdf	05/29/2019

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