SSA-1691 - Current

Form SSA-1691 (10-2017)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0699

Eligible Non-Attorney Representative Application
You must complete this application carefully and provide all supporting documentation as required. You
must provide all required information once you pass the examination in order to receive direct payment of
fees. If you have any questions, please access the Representing Social Security Claimants Website at
http://www.ssa.gov/representation/.
Purpose of this Form
Section 3 of the Social Security Disability
Applicants’ Access to Professional
Representation Act (PRA) Public Law no.111-142
provides for permanent extension of direct
payment of SSA-approved fees to certain nonattorney representatives. Under the PRA, to be
eligible for direct payment of fees, a non-attorney
representative must fulfill the following statutory
prerequisites: (1) possess a bachelor’ s degree or
have equivalent qualifications derived from
training and work experience; (2) pass an
examination that tests knowledge of the relevant
provisions of the Social Security Act; (3) secure
professional liability insurance or equivalent
insurance; (4) pass a background check; and (5)
demonstrate completion of relevant continuing
education courses. SSA must collect the
requested information to determine if a nonattorney representative has met the prerequisites
to be eligible for direct payment of fees for his or
her claimant representation services. The
information collection is needed to comply with
the legislation. The respondents are non-attorney
representatives who apply for direct payment
of fees.
Application Fee
PRA section 3(a) provides that the
Commissioner may assess applicants a
reasonable fee to cover the costs of
administering the prerequisites process. The
non-refundable fee is listed on the
Representing Social Security Claimants
Website at http://www.ssa.gov/representation/;
Applicants must include the non-refundable fee
payment with their application package;

Acceptable forms of fee payment will be by
check, money order, or a check drawn from a
private firm's account;
Applicants will pay their fees to the entity listed
on the Representing Social Security Claimants
Website at http://www.ssa.gov/representation/;
and
Applicants found ineligible to take the
examination or who fail the examination may
apply in any future application period, but must
then again pay the full fee.
Education and Equivalent Qualifications
A bachelor’s degree from an accredited
institution of higher education is a prerequisite
to receive direct payment of fees. Applicants
who do not have a bachelor’s degree may
satisfy this prerequisite based on a
combination of holding a high school diploma
or general education diploma (GED) plus four
years of relevant professional experience that
the Commissioner determines to be equivalent
to a bachelor’s degree.
Relevant professional experience is training or
work through which the applicant demonstrates
familiarity with medical reports and an ability to
describe and assess mental and/or physical
limitations. Such experience may be from the
fields of: teaching, counseling or guidance,
social work, personnel management, public
employment service, and/or nursing or other
health care professional services. Professional
work involving claims for benefits under Title II
or Title XVI of the Act is considered relevant
professional experience.
An applicant must submit proof of a bachelor’s
degree or equivalent qualifications after he or
she passes the examination.

Form SSA-1691 (10-2017)

Failure to do so precludes the applicant from
establishing his or her eligibility to receive
direct payment of fees. Proof of education is an
official transcript showing the stamp or raised
seal. Proof of relevant professional experience
includes, but is not limited to an Internal
Revenue Service (IRS) Form W-2(s), Wage
and Tax Statement(s), and letters from
employers.
Attorneys who have fees paid directly from their
clients' past-due benefits pursuant to sections
206 and 1631(d)(2) of the Act are not required
to take the examination. Attorneys who are
suspended or disbarred by a State or Federal
court or disqualified from appearing before a
Federal agency or program are not eligible to
receive direct payment and should not submit
an application.

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coverage in order to continue to receive
direct payment of fees from SSA.
Background Check
A background check is required of each
applicant to ensure his or her fitness to practice
before SSA. SSA rejects any applicant who:
•

has been suspended or disqualified
from practice before SSA;

•

has had a judgment or lien assessed
against him/her by a civil court for
malpractice and/or fraud;

•

has had a felony conviction;

•

has failed to provide the required
documentation enabling SSA to
perform the criminal background
investigation;

•

has substantially misrepresented the
facts in submitting his or her application;

•

fails to pass an SSA administrative
records check (check of SSN, etc.).

Types of Insurance
Applicants are required to have professional
liability insurance or equivalent insurance,
which the Commissioner has determined to be
adequate to protect claimants in the event of
malpractice by the non-attorney representative.
The insurance policy must be underwritten by a
firm that is licensed to provide insurance in the
State in which the non-attorney representative
conducts business. The policy must also provide
coverage for professional liability insurance
claims made in those States in which the nonattorney representative represents claimants
before SSA.
See the Representing Social Secuirty Claimants
Website at http://www.ssa.gov/representation/
for professional and business liability insurance
coverage amounts.
An applicant must submit proof of the required
insurance after he or she passes the
examination. Failure to do so precludes the
applicant from establishing his or her eligibility
to receive direct payment. An applicant who
establishes eligibility to receive direct payment
will be required to maintain insurance

Examination
Applicants are required to pass an examination
testing their knowledge of the relevant
provisions of the Act and the most recent
developments in Agency and court decisions
affecting Titles II and XVI of the Act. The
examination will consist of 40 to 50 multiplechoice questions. Examination details are as
follows:
•

The examination instrument is written in
the English language only;

•

The examination will be given only once,
on a weekday, in conjunction with each
application period;

•

During the examination, test-takers will
have open-book access to certain
reference materials that we will supply
(see below for details);

Form SSA-1691 (10-2017)

• The examination will be based upon
situations that arise from the subject
areas contained in the reference materials.
• Applicants will not be permitted to remove
the examination instrument or reference
materials from the examination center.
SSA provides the 20 CFR, Chapter III (Parts
400-499) for open-book reference. Applicants
will not be permitted to bring any other
(including reference materials) to the
examination center.
Applicants who fail to achieve a passing score
may re-apply during a subsequent application
period; however, they will be required to pay
the application fee again.
Continuing Education Courses (CE)
Applicants who become eligible non-attorney
representatives must complete courses to meet
the continuing education requirement. The
courses must enhance eligible non- attorney
representatives’ professional knowledge in
matters such as those related to entitlement to
benefits, ethics, listing of impairments, and
other disability topics under Titles II and XVI of
the Act. We will prescribe the course(s) and
notify eligible non-attorney representatives of
when to complete and how to certify that they
have completed the course(s).

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Instructions for Completing this Form
•

Please type or print legibly using only a
BLUE or BLACK ink pen.

•

Completely fill out all sections of this
form. Use "None" or "N/A" where
applicable.

•

Include an area code with all telephone
numbers.

•

Include a zip code with all addresses.

•

List your full middle name. If you do not
have a middle name, please indicate this
by showing "NMN" for a middle name.

•

Line out and initial any changes you
make to your application.

•

If you require additional space, please
use Section D. Please indicate the
section and question number you are
responding to before you record the
additional information.

Form SSA-1691 (10-2017)

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Please read the instructions on pages 1 through 3 of this application for eligibility requirement.
SECTION A

Background Information – Applicant’s Identifying Information

First Name:

Full Middle Name:

Last Name:

Suffix:

Other Name(s) Used:
Reason(s) for other name(s) used:
SSN:
Citizenship Status:

Date of Birth (mm/dd/yyyy):
U.S. Citizen

Naturalized Citizen

Alien Authorized to work in the U.S.

Other If other, please specify:
SECTION A

Background Information – Applicant’s Contact Information

Address:

Home Phone:

Address (Line 2):

Mobile Phone:

City:

State:

Zip Code:

Work Phone:

E-mail Address:
SECTION A

Background Information – Additional Information

1. Are you a licensed or practicing attorney?
OR
Are you an attorney who has been disbarred or suspended from
practicing in any state?

Yes

No

Yes

No

Yes

No

If yes to either of these questions, stop. Do not submit this application.
Licensed or practicing attorney are not required to take the
examination in order to receive direct pay. Disbarred or suspended
attorneys are not eligible to take the examination.
2a. Do you have a bachelor's degree from an accredited institution of
higher education?
(If Yes, go to question 3. If No, please answer question 2b.)

2b. Do you have equivalent qualifications?
(Only respond if you answered No to question 2a.)

Form SSA-1691 (10-2017)

SECTION A

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Background Information – Additional Information (continued)

3. Have you been, by reason of misconduct, disqualified, sanctioned, or
suspended from participating in any Federal program or appearing
before the Social Security Administration or any other Federal Agency?

Yes

No

Name of Program or Agency:
Address of Program or Agency:
If Yes, please provide the following
information:

Details of Disqualification, Sanction or Suspension:

Date of disqualification, sanction
or suspension:
4. Are you currently being investigated by reason of misconduct, by the
Social Security Administration or any other Federal agency for
possible disqualification, sanction, or suspension?

Date of Reinstatement
(if applicable):
Yes

No

Name of Program or Agency:
Address of Program or Agency:
If Yes, please provide the following
information:

Details of Investigation:

Date of Investigation:

Status of Investigation:

5. Have you been determined to have fraudulently used or misused any
Social Security benefits?

Yes

No

6. Have you had a judgment or lien assessed against you by a civil court
for malpractice and/or fraud?

Yes

No

7. Have you ever had a felony conviction?

Yes

No

8. Have you been determined to have violated any Social Security
program rules (e.g., rules regarding the disclosure of evidence or
representative payee rules)?

Yes

No

9. Have you applied for the Social Security Administration Non-Attorney
Representative Examination before?

Yes

No

Date of Previous Application(s):
Disposition of Previous Application:
If Yes, please provide the following
information:

Any Changes to Report Since Previous Application:

Form SSA-1691 (10-2017)

SECTION B

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Education/Equivalent Qualifications - College/University Attended

Please provide information on the accredited College or University from which you received your bachelor’s
degree or higher. Once you pass the examination, you must provide proof of your highest degree in the form
of an official transcript showing the stamp or raised seal, or otherwise establishing that it is an official copy.
Name of College/University:
Attended From (mm/yyyy):
Indicate degree granted:

City:
Attended To (mm/yyyy): Degree Granted?
Doctorate Degree

State:
Yes

Graduate Degree

No

Bachelor’s Degree

If you do not have a bachelor’s degree or higher from an accredited College or University, you must
provide information regarding your High School Diploma or GED. Once you pass the examination, you must
provide proof in the form of a copy of your high school transcripts, diploma, or GED certificate (or other
equivalent documentation).
Date Diploma or Certificate Awarded (mm/yyyy):
High School or GED Certificate:
City:
SECTION B

State:
Education/Equivalent Qualifications - Relevant Professional Experience

If you have a bachelor’s degree or higher, skip this section. If you do not have a bachelor’s degree or
higher, provide information about relevant professional experience. You must provide four years of relevant
training or work experience through which you have demonstrated familiarity with medical reports and an
ability to describe and assess mental and/or physical limitations. Such experience may be from the fields of:
teaching, counseling or guidance, social work, personnel management, public employment service, and/or
nursing or other health care professional services. Any work experience involving claims for benefits under
Title II or title XVI of the Act shall also be defined as relevant professional experience. In the Position
Description field, you must add enough detail for SSA to determine if the cited experience constitutes
relevant professional experience. Once you pass the examination, you must provide proof (e.g., IRS Form
W-2, wage and tax Statement (s)) of your professional experience.
1. This experience is:

SSA Related Professional Experience

Other Professional Experience

Position/Title:
Position Description:

Name of Employer:
Address:
City:

State:

Name of Supervisor:

Employer Phone:

2. This experience is:
Position/Title:
Position Description:

SSA Related Professional Experience

Zip Code:

Other Professional Experience

Form SSA-1691 (10-2017)

SECTION B

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Education/Equivalent Qualifications - Relevant Professional Experience (continued)

Name of Employer:
Address:
City:

State:

Zip Code:

Name of Supervisor:

Employer Phone:
If you require additional space, please use Section D

SECTION C

Examination Information

The exam will be administered at designated locations across the country. The exam will be held on the
same date at each location. SSA may cancel any site if enrollment does not meet minimum standards. In
that event, applicants will be notified at least 20 days prior to the test date in order make appropriate travel
arrangements to an alternate test site. See the Representing Social Security Claimants Website at
http://www.ssa.gov/representation/ for a list of exam locations. Applicants will be asked to select a first and
second choice for their examination location (for use if they pass a criminal background check and are
eligible to sit for the exam). Applicants who timely submit their applications but fail to select a second choice
will have their applications denied as incomplete. Applicants who timely submit their applications but repeat
their first choice as their second choice will be contacted and given the opportunity to correct the defect by
selecting a second choice examination site that is different from the first choice examination site. This
information will be used by SSA in the event the first choice examination site is cancelled. Please provide
your top two (2) choices for your examination location. Detailed information concerning the specific
location of the examination site will be mailed to those applicants determined eligible to sit for the
examination.
First Choice Location

City:

State:

Second Choice Location City:

State:

Please describe any special accommodation you will need at the examination location. Please note that you
must provide supporting documentation from a professional qualified to determine your condition along with
your application to the address indicated on the Representing Social Security Claimants Website at
http://www.ssa.gov/representation/.

Please initial indicating that you understand that you must provide written documentation to Initials:
support your request for special accommodations along with your application.

Form SSA-1691 (10-2017)

SECTION D

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Additional Information

Form SSA-1691 (10-2017)

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Privacy Act Statement
Collection and Use of Personal Information
Section 206(e) of the Social Security Act, as amended, allows us to collect this information. Furnishing us
this information is voluntary. However, failing to provide all or part of the information may result in a
determination that you are ineligible to receive direct payment of fees.
We will use the information to help us determine your eligibility to receive direct payment of representative
fees. We may also share your information for the following purposes, called routine uses:
1. To contractors and other Federal agencies, as necessary, to assist us in efficiently administering
our programs. We will disclose information under this routine use only in situations in which we
may enter into a contractual or similar agreement with a third party to assist in accomplishing an
agency function relating to this system of records; and
2. To student volunteers, persons working under a personal services contract, and others who are not
technically Federal employees, when they are performing work for us, as authorized by law, and
they need access to information in our records in order to perform their assigned duties.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person’s eligibility for federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0325,
entitled Appointed Representative File. Additional information and a full listing of all our SORNs are available
on our website at www.socialsecurity.gov/foia/bluebook.

Please initial indicating that you have read and understand the Privacy
Act Statement.

Initials:

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 Budget control number. We estimate that it will take 30-45 minutes to read the
instructions, gather the facts, and answer the questions. Send only comments relating to our time
estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
Please initial indicating that you have read and understand the Paperwork
Initials:
Reduction Act Statement.

Form SSA-1691 (10-2017)

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Substantial Misrepresentation or Material Discrepancy Statement
If I cannot substantiate my application or it is determined that the information I entered is incorrect, I
understand that I may be determined ineligible to sit for the examination or to receive direct payment
of fees.
Please initial indicating that you have read and understand the Substantial
Initials:
Misrepresentation or Material Discrepancy statement.
Application Fee Statement
The application fee is non-refundable. See the Attorneys and Appointed Representatives Website for
additional information.
Please initial indicating that you have read and understand the statement
Initials:
regarding the applicable fee.
Statement of Understanding
I understand that I must sign the application in ink and submit the application fee and complete
application package to the address indicated on the Representing Social Security Claimants
Website at http://www.ssa.gov/representation/. I also understand that I will be required to complete,
sign, and submit a release form necessary for the criminal background check with this application.
This application package must be postmarked or receipt-dated (if sent by private express service)
by midnight E.D.T. of the last day of the application period. I further understand that the application
fee is generally non- refundable. SSA will not process my application until the completed
application package is received. If this requirement is not met as of midnight E.D.T. of the last day
of the application period, SSA will process my application as a denial. See the Representing Social
Security Claimants Website at http://www.ssa.gov/representation/ for information about the
application period.
Please initial indicating that you have read and understand the Statement of
Initials:
Understanding statement:
Penalty of Perjury Statement
I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true and correct to the best of my knowledge. I
understand that anyone who knowingly gives a false statement about a material fact in this
information, or causes someone else to do so, commits a crime and may be subject to a fine or
imprisonment.
Signature (sign in ink)

Date:

Form SSA-1691 (10-2017)

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Social Security Administration
PLEASE READ CAREFULLY
APPLICANT AUTHORIZATION FOR RELEASE OF INFORMATION

I authorize SSA to conduct a criminal background check in which SSA may secure any criminal history
information pertaining to me that may be in the files of any Federal, State, or Local criminal justice agency.
I authorize any Federal, State, or Local criminal justice agency to release to SSA any criminal history
information pertaining to me that may be in the agency’s files. I authorize SSA, and any of its agents, to
disclose orally and in writing the results of this criminal background check to the business entity that
manages the information for managing direct payment eligibility for non-attorney representatives.
I understand that the results of the criminal background check may be used by SSA to determine my
eligibility to sit for the examination and receive direct payment, and may not otherwise be used except as
authorized by law. In the event that SSA uses information from the criminal background check in
whole or in part in making an adverse decision with regard to my eligibility to sit for the examination or
to receive direct payment, I understand that SSA will provide me a copy of the report on the criminal
background check submitted by SSA and a description in writing of my right to protest the decision to SSA.
I understand that submission of this authorization is voluntary. I also understand that failure to provide the
authorization and information required to conduct a criminal background check will cause SSA to deny my
application.
I understand that copies of this authorization that show my signature are as valid as the original, and that
this authorization is valid for 6 months from the date signed.
CRIMINAL BACKGROUND CHECK INFORMATION
Applicant Last Name:

First Name:

Middle Name:

Social Security Number:

Date of Birth:

Place of Birth:

Sex:

Race (Optional):

Current Address:

Please list all of the addresses you have lived at in the last 5 years
City/State/Zip Code:
From: (mm/dd/yyyy) Present:

Previous Address:

City/State/Zip Code:

From: (mm/dd/yyyy) To: (mm/dd/yyyy) -

Previous Address:

City/State/Zip Code:

From: (mm/dd/yyyy) To: (mm/dd/yyyy) -

Previous Address:

City/State/Zip Code:

From: (mm/dd/yyyy) To: (mm/dd/yyyy) -

Applicant’s Signature

Date:

Daytime Phone: