Appointment of Representative - SSA-1696

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Claimant's Appointment of Representative
Form SSA-1696 (12-2020) UF
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Social Security Administration

Page 3 of 6
0MB No. 0960-0527

Claimant's Social Security Number

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Appointed Representative's Rep ID

Claimant's Appointment of a Representative

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First Name

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Section 1 - Claimant's Information
lnmal

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Mailing Address

State

City
Phone Number

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Name

ZIP/Postal Code Country - if outside the U.S.

Alternate Phone Number (Optional)

Number Holder's Information (Complete when applicable)

My claim is based on another person's work or earnings (e.g., spouse or parent). This person's information is different from mine.

Number Holder's Social Security Number
First Name

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1nma1 Last Name
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Section 2 - Disclosure

(Claimant Only)

D By selecting this box, I, the claimant listed in Section 1, whose signature appears in Section 8, authorize SSA to release

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information in relation to my pending claim(s) or asserted right(s) to designated associates who perform administrative duties
(e.g., clerks, assistants), partners, or parties under contractu,al arrangements for or with my representative. (The appointed
representative's partners, associates, delegates and designees must be prepared to provide information in order to be
authenticated.)

Section 3 - Principal Representative (Claimant only- Complete when applicable)

I have appointed before, or appoint now, more than one representative. I ask SSA to make contacts or send notices to this
individual. My principal representative is:
Name

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Claimant's Appointment of Representative

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Form SSA-1696 (12-2020) UF

II

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Claimant's Social Security Number

Appointed Representative's Rep ID

Section 4 - Representative's Information
Representatives who are eligible and seek direct payment of their fee must register and receive a Rep ID before the appointment
For more •i nformation about registration visit us on-line at wwwsocja1secucity goy/ar contact us at 1-800-772-1·2 13
(TTY 1·-ao0-325-0778), or visit your local Social Security of fice.

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*First Name

Initial Last Name

Mamng Address

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"ZIP/Postal Code Countrv - if outside the U.S.

Citv

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Phone Number

Alternate Phone Number (OptionaJ)

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State

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Section 5 - Representative's Status, Affiliations, and Certifications
Representative's Status Part A - Type of Representative (Representatives have a duty to keep their i nformation current)

*o I am an attorney (SSA law states that an attorney is someone in good standing who has the right to practice Jaw before a
court of a State, Teffifory, District, or island possession of the United States, or before the Supreme Court or a lower
Federal court of the United States.)

* 0 I am a non-attorney eligible for direct payment (SSA law requu-es that non-attorneys meet certain criteria to qualify for direct
payment Refer to our website at www.ssa.gov/representation for criteria).

*0 I am a non-attorney not eligible f or direct payment

D I work for a non-profit organization (e.g. a law clinic or s1ate legal aid)
Representative's Status Part B - Disqualification

I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice law.
*Q Yes *Q No
I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.

* 0 Yes* O No

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Claimant's Appointment of Representative

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Form SSA-1696 (12-2020) UF

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II

Page 5 of 6

Claimant's Social Security Number

Appointed Representative's Rep ID

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Section 5 - Continued
Affiliation Information
If you are representing the claimant(s) as a partner or employee of a business entity, firm or other organization you may provide
your Employer Identification Number (EIN) here, if one exists for tax purposes. This number is not your Social Security Number
(SSN). This is your employer's tax identification number. (Do not complete this section if you do not qualify for direct payment.)

s�t

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Organization's Name (Enter the full name of the business, entity. firm or organization with which you want to be affiliated while
representing this claim)

Representative's Business Address (if different than mailing address)

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Citv

Country - jf outside the U.S.

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State

ZIP/Po•taJ Cod•

Representative' ,s Certifications

I accept this appointment and certify the following:
• I understand and agree that I will comply with SSA's laws and rules on the representation of parties, including the Rules of
Conduct and Standards of Responsibility for Representatives; I wiU not charge, collect, or retain a fee for representational
services that SSA has not approved or that is more than SSA approved unless a regulatory exclusion applies.
• I understand that if I fail to comply with any of SSA's laws and rules I may be suspended or disquarified as a representative
before SSA.
• I will not disclose any information to any unauthorized party without the claimant's specmc written consent.
• I am not currently suspended or prohibited, for any reason, from practicing before the Social Security Administration.
• I am not disqualmed from representing the claimant as a current or former officer or employee of the United States.
• I accept appointment as the representative for the claimant named in Section 2 of this form in connection with the claims and
asserted rights described in Section 6 of this form.
• I agree that a copy of this signed form SSA-1696 will have the same force and effect as the original.
• I declare under penalty of perjury that I have examined all of the information on this form and on all accompanying statements or
forms, including any information, attestations and certifications provided to SSA in registration, and that they are all currently true
and correct to the best of my knowledge.
ff I intend to seek direct payment of the authorized fee on this claim • I have registered for and obtained a Rep ID, and my registration information is up-t�date.
• I have provided up-to-,date information on my registration concerning whether I have been suspended or prohibited from practice
before SSA or any other Federal program or agency, disbarred or suspended by a court or bar, and convicted of a violation
under Section 206 or 1631 (d) of the Social Security Act

I CERTIFY TO ALL OF THE ABOVE

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