Information Collection

SSA-1696 (0960-0527) - 404.1730(e)(2); 416.1530(e)(2) - A representative may rescind an assignment before the date on which we notify you of our first favorable determination or decision

IC 261467 under ICR 202408-0960-006 · OMB 0960-0832.

Documents and Forms

Document Name Document Type
Form SSA-1696 SSA-1696 (0960-0527) - 404.1730(e)(2); 416.1530(e)(2) - A representative may rescind an assignment before the date on which we notify you of our first favorable determination or decision Form and Instruction
Form SSA-1696 SSA-1696 (0960-0527) - 404.1730(e)(2); 416.1530(e)(2) - A representative may rescind an assignment before the date on which we notify you of our first favorable determination or decision 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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SSA-1696 (0960-0527) - 404.1730(e)(2); 416.1530(e)(2) - A representative may rescind an assignment before the date on which we notify you of our first favorable determination or decision	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 404.1730(e)(2) 20 CFR 416.1530(e)(2)

Information Collection 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 Fileable Signable
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: 150,000	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150,000	150,000
Annual IC Time Burden (Hours)	7,500	7,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.