Information Collection

SSA-1696 (0960-0527) - 404.1707(a); 416.1507(a) - You [claimant] complete and sign our prescribed appointment form

IC 261464 under ICR 202408-0960-006 · OMB 0960-0832.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1696 SSA-1696 (0960-0527) - 404.1707(a); 416.1507(a) - You [claimant] complete and sign our prescribed appointment form	Form and Instruction
Form SSA-1696 SSA-1696 (0960-0527) - 404.1707(a); 416.1507(a) - You [claimant] complete and sign our prescribed appointment form	Form and Instruction
SSA-1696 Claimant's Appointment of a Representative SSA-1696 (Revised Version).pdf www.ssa.gov	Form and Instruction
SSA-1696 Claimant's Appointment of a Representative SSA-1696 (Revised Version).pdf www.ssa.gov	Form and Instruction
SSA-1696-APP Claimant’s Appointment of a Representative SSA-1696-APP Screens (Revised Version).pdf www.ssa.gov	Form and Instruction
SSA-1696-APP Claimant’s Appointment of a Representative SSA-1696-APP Screens (Revised Version).pdf www.ssa.gov	Form and Instruction
SSA-1696 (Current Version).pdf Current SSA-1696	IC Document
SSA-1696 (Current Version).pdf Current SSA-1696	IC Document
SSA-1696-APP Screens (Current Version).pdf Current SSA-1696-APP Screens	IC Document
SSA-1696-APP Screens (Current Version).pdf Current SSA-1696-APP Screens	IC Document

IC Title:

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 416.1507(a) 20 CFR 404.1707(a)

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	Claimant's Appointment of a Representative	SSA-1696 (Revised Version).pdf	www.ssa.gov	Yes	Yes	Fillable Printable
Form and Instruction	SSA-1696-APP	Claimantâs Appointment of a Representative	SSA-1696-APP Screens (Revised Version).pdf	www.ssa.gov	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,100,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,100,000	1,100,000
Annual IC Time Burden (Hours)	128,333	128,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-1696	SSA-1696 (Current Version).pdf	08/12/2024
Current SSA-1696-APP Screens	SSA-1696-APP Screens (Current Version).pdf	08/12/2024

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