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Complete the Fee Agreement for Representation Before the Social Security Administration (Form SSA-1693)
Instructions for Representatives
This service allows you to electronically complete the Fee Agreement for Representation Before the Social Security Administration (Form SSA1693). You, the claimant, and up to five additional representatives may sign the form and submit it to us electronically. Do not use this electronic
form if there are more than six representatives who will be seeking a fee for services provided on this claim. Before you begin, you will need
the following information:
• Your valid email address.
• The claimant's valid email address.
• The valid email addresses and up to five additional representatives who will be signing this fee agreement.
IMPORTA!YI: We will not receive or process the form until you, the claimant, and any additional representative(s) whose email address(es) you
provide have completed the steps below and electronically signed the form.
Step One. You, the Appointed Representative, must complete your designated sections of the forrn, sign the fonn electronically, and select
"Click to Sign" to subrnit the form.
Before beginning the fonn, you will first enter and confirm the email addresses for you, the claimant, and up to five additional representative(s)
into the application online. We will refer to these individuals as "all parties" in these instn1ctions.
You will also create a password that will be required for all pa1ties to access the form. You should provide the password to the other parties by
phone, in person, or SMS text message (standard message and data rates may apply). If you are unable to contact the other parties by phone, in
person, or by text, then you may send the password in a separate email message. You will not be able to reset the password. If it is lost or forgotten,
you will have to restart the process.
You will receive an email from [email protected] containing a link and instructions on how to access the form.
NOTE: After you submit the form, all other parties will receive an email from [email protected] containing a link and instn1ctions for
accessing and signing the form. The forrn must be completed by all parties within ten (10) calendar days after you initiate the process online (i.e.,
when you enter all of the parties' email addresses in order to receive an email with a link to the fon11). You should inform all pa1ties about the
importance of taking action upon receipt of the email. If all parties do not complete, sign, and submit the form within ten ( 10) calendar days, you
will need to restart the process.
Step Two. After you have completed Step One, the remaining pa1ties will receive an email with a link to access and review the partially completed
form, complete their designated sections, sign the form electronically, and select "Click to Sign" to subrnit the forrn. There is no specific order
required for the other parties to complete the form, but all must electronically sign and subrnit it within the 10-day period.
After successful submission of the form by all pa1ties, [email protected] will send an email to all parties with a link to the completed
form. This will allow you to save a copy for your records using the pre-established password.
PLEASE NOTE:
• This website is most compatible with the following browsers: Microsoft Edge and Google Chrome.
• When accessing the form, the system will end your session after 60 minutes of inactivity. Use the link in your email and your pre-established
password to continue working on your form.
• A daily email reminder will be sent to the necessary parties until the form has been submitted or until the time expires (i.e., ten (10) days after
initiation).
• You, the Appointed Representative, will have to restart the process if any of the following situations apply:
o The password is lost or forgotten. The password cannot be reset.
o You (or the other parties) do not receive an email notification within a few minutes of your online submission. Be sure to check your
junk folder.
o All parties do not electronically sign and submit the form within ten (10) calendar days.
Sections 206 and 1631(d) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is
voluntary. However, failing to provide all or pa1t of the information may affect the amount of fees authorized for services rendered before us.
We will use the infonnation you provide to authorize fees for services rendered to the claiinant named on the form. We may also share your
information for the following purposes, called routine uses:
• To a claimant's representative to the extent necessary to dispose of a fee petition or fee agreement; except for pre-decisional
deliberative documents, such as analyses and recornmendations prepared for the decision-maker;
• To contractors and other Federal agencies, as necessa1y, for the purpose of assisting us in the efficient administration of our prograrns;
and
• To the Internal Revenue Service and to State and local government tax agencies in response to inquiries regarding receipt of fees we
paid directly starting in calendar year 2007.
In addition, we may share this infonnation in accordance with the Privacy Act and other Federal laws. For example, where authorized, we
may use and disclose this information in computer matching prograrns, 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 Notices (SORN) 60-0003, entitled Attorney Fee File, as
published in the Federal Register (FR) on Janua1y 11, 2006, at 71 FR 1803; 60-0089, entitled Claims Folders System, as published in the FR
on October 31, 2009, at 84 FR 58422; and 60-0325, entitled Appointed Representative File, as published in the FR on October 8, 2009, at 74
FR 51940. Additional information and a full listing of all our SORNs are available on our website at www.ssa.gov/privacy.
� I understand and agree to the above statement
Start Application
© Social Security
Fee Agreement for Representation
We recommend that you verify the accuracy of the email addresses of all parties and make note of the password prior to
submission.
You will have to restart the process if any of the following situations apply:
• The password is lost or forgotten. The password cannot be reset.
•
You do not receive an email notification within a few minutes of your online submission. Be sure to check your junk folder.
•
All parties do not electronically sign and submit the form with in ten (10) calendar days.
Appointed Representative's Email
Enter Appointed Representative's Email
Confirm Appointed Representative's Email
Confirm Appointed Representative's Email
I
I
I
Claimant's Email
Enter Claimant's Email
Confirm Claimant's Email
Confirm Claimant's Email
Representative #2's Email
Enter Representative #2's Email
Confirm Representative #2's Email
Confirm Representative #2's Email
Add Signer
G
Remove Signer G
Document Name
Fee Agreement for Representation Before the Social Security Administration
Password Required
Password must contain at least 8 characters, 1 uppercase, 1 lowercase, and 1 number.
Password
Confirm Password
D
Show Password
Completion Deadline
08/13/2021
Submit
© Social Security
Fee Agreement for Representation
To complete the online form, open the email from [email protected] and click on the
"Review and sign" button.
Wtd 6/9/2021 9:45 AM
Social Security Administration
[EXTERNAL] Social Security Administration Has Sent You Fee Agreement for Representation Before the Social Security Administration
To Appointed Rep Email Address
Rdtntion Policy 0,1,t,_7_Ytar_Dtfault (7 y,ars)
0 If tht!rt! art! problt!ms with how this mt!Ssagt! is displayt!d, click ht!rt! to vit!W it in a v.!b browst!r.
E.xpi"s 6n/2028
� Social Security
Social Security Administration requests your signature
Fee Agreement for Representation Before the Social Security Administration
Form Expires On June 14, 2021
Review and sign
THIS LINK EXPIRES IN TEN (10) CALENDAR DAYS.
You have a document to review and sign. You can access the document using the link above. For additional security, the appointed
representative has set a password for this document. If you are not the appointed representative, you will need to contact the appointed
representative to get the password in order to review this document. If any of the information in the document is incorrect or if you
disagree with any of the information, the appointed representative should restart the process.
This link is personalized for you and, for security purposes, we recommend that you do NOT forward/share this email or link with others.
If you DO forward/share this email or link with others, you accept the risk that, by sharing your personal information, the person assisting
you may misuse your personal information. If you have any questions about this email or feel that you received this in error, please
contact SSA at 1-800-772-1213 (TTY 1-800-325-0778) between 8:00 am - 7:00 pm, Monday through Friday.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit https://oig.ssa.gov/report or call the Inspector General's Fraud Hotline at 1-800-2690271 (TTY 1-800-501-2101).
SOCIAL SECURJTY ADMINISTRATION
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*** NOTE for mock-up of changes: All instructions,
Please replace the
Paperwork Reduction ACT, and Privacy statement will
date to reflect
befor
updated
to match the
revised
If the section
11/30/2024. This
Fee Agreement
Representation
Before
theSSA-1693.
Social Security
Ad...
is repeated a second or third time in this screen package
change should be
this is to show the flow of the user. The edits are not
reflected throughout
the entire document.
Fonn SSA-1693 (31XX/2021) repeated throughout the document***
Please replace the first sentence in
the registration section: "Beginning
September 30, 2024, all
representatives must register with us
using Form SSA-1699
Representative Registration prior to
being appointed. They will receive a
Representative ID (Rep ID) once the
registration is processed."
Note: Please use this replacement
language in all duplicate sections of
the screenshots to ensure consistency
and accuracy throughout the
document.
Replace the deleted
sentence with the
following sentence: "You
or your representative
must file your fee
agreement before we issue
a favorable determination
or decision in your case."
Note: Please use this
replacement language in
all duplicate sections of
the screenshots to ensure
consistency and accuracy
throughout the document
Replace the strike through text with
the following information: "Although
representatives may only use either a
fee agreement or a fee petition in each
case (they are mutually exclusive),
you and your representative can limit
the effect of a fee agreement to a
certain appeal level. Representatives
can file a fee petition if your case is
appealed beyond the specified
administrative level. You and your
representative can choose this option
on the attached form."
Note: Please use this replacement
language in all duplicate sections of
the screenshots to ensure consistency
and accuracy throughout the
document.
Replace the deleted text with the
following language: If your
representative is eligible under our
rules to receive an authorized fee
directly from us, we usually
withhold 25 percent of your TII/
TXVI past-due (retroactive)
benefits for direct payment of that
fee. For more information on when
you must pay your representative
the authorized fee directly,V,visit
a,
our Public Policy page at https://
secure.ssa.gov/apps10/poms.nsf/
lnx/0203920006.
--
Social Security Administration
field
II
0MB No. 0960-0810
Note: Please use this replacement
language in all duplicate sections
of the screenshots to ensure
consistency and accuracy
throughout the document.
INSTRUCTIONS FOR COMPLETING FORM SSA-1693
YOU DO NOT HAVE TO SIGN THIS FORM - Your appointed representative initiated this fonn online. Use and sign this fonn only
if you agree to its tenns. If you do not agree, do not sign it Refusing to sign the fonn will not affect how we will process your
claim, or our future decisions about it In this document, "you• means the claimant, beneficiary, auxiliary, or spouse. In this
document, "us• and "SSA" means the Social Security Administration. Do not file fonn SSA-1693 unless you have appointed the
representative (e.g., filed an SSA-1696) for a claim or issue you have pending with us.
If you suspect Social Security Fraud, please visit http://oig.ssa.gov/report or call the Inspector Generars Fraud Hotline
at 1-800-269-0271 (TTY 1-866-501-2101).
Requesting a fee for representational services
Your appointed representative can ask for a fee for the services he or she provided in your claim. Not all representatives ask for a
fee, and some only charge a fee if they win your case. To charge you a fee, your representative(s) generally must get our
approval. Your representative can get our approval by submitting a fee agreement (you may use this form) or a fee petition. You
and your representative choose which of these two processes to 1J1Se. Under the fee agreement process, the amount your
representative can ask for is limited by the Social Security Act Under the fee petition process, your representative can ask for a
higher fee. For more infonnation on fees, fee processes, and our rules, visit our website at www.ssa.gov/representation.
Registration
Representatives who seek direct payment of their fee mustfirst register with us. For more infonnation on representative
registration, visit us online at www.ssa.gov/ar, contact us at 1-800-772-1213 (TTY 1-800-325-0778). or contact your local Social
Security office.
When t o file a fee agreement
Your representative(s) must file your fee agreement before we issue a favorable decision in your case. If you or your
representative(s) submit the fee agreement after our decision, we will disapprove your fee agreement.
Replace "he and she" with
"they" for gender neutral
language.
Note: Please use this
replacement language in all
duplicate sections of the
screenshots to ensure
consistency and accuracy
throughout the document.
Replace the deleted text
with the following
language. If you or your
representative submit
the fee agreement after
our determination or
decision, we will
disapprove your fee
agreement.
What you have to pay
Under the terms of a fee agreement, you agree to pay an amount up to 25 percent of your total past-due benefits or an amount
set by us. whichever is less. You must pay the fee we authorize. Your spouse, dependents or your auxiliary beneficiaries will also
pay a fee unless they have their own representation. In addition to the fee we authorize, you may also have to pay:
• Fees authorized by a Federal court for services your attorney provided during court proceedings, and
• Any "out-of-pocket• expenses your representative may incur (e.g., costs for making copies of a doctor's or hospital's records). Replace "he and she" with "they" for
gender neutral language.
Note: These fees and expenses do not require our authorization.
Note: Please use this replacement
Two-tiered fee agreements
You and your representative(s) should complete this field only if you want to limit the effect of this fee agreement to a certain
administrative level. If you choose this option and your case is appealed beyond the specified administrative level, your
representative(s) can file a fee petition. Under the fee petition process, the authorized fee may be higher than the amount
that can be authorized under the fee agreement process.
Trust or escrow accounts
Your representative may accept money from you before we authorize a fee as long as he or she holds it in a trust or escrow
account according to our rules and policy. If you choose to enter into the trust or escrow agreement with your representative,
you may willingly deposit the money in the trust or escrow account and tell us on this form. Only complete this field if your
representative is using an escrow or trust account.
Third-party payments
We collect infonnation on payments your representative may receive from a third party for services he or she provided to you
during the administrative proceedings. These fees may be in lieu of your fee payment, or may be in addition to your payment.
We may consider these payments during our authorization process to detennine if we need to authorize these fees under our
rules. All statutory and regulatory rules continue to apply in situations involving third-party payments.
Withholding of funds and direct payment t o your representative
If your representative is eligible under our rules to receive an authorized fee directly from us out of your past-due benefits, we
usually withhold 25 percent of your past-due benefits for direct payment of that fee. However, you are responsible for paying
your representative the authorized fee if:
• the amount of the fee we approve is more than the amount held for you in a trust or escrow account, or more than the amount
we can pay to your representative from your past-due benefits,
--.v
Language I English: US
Replace the deleted text
Instruction language changed to:
Next required
"File Form SSA-1693 only if you
or your representative are
submitting or have submitted a
notice of appointment on a
pending claim, matter, or issue."
1
--
Js
8
(±)
.!.
language in all duplicate sections of the
screenshots to ensure consistency and
accuracy throughout the document.
Replace the word
"holds" with
"hold"
Replace " he or
she" with your
representative
Remove all text language and bullets
beginning with " However" Replace
with the following language: "For more
information on when you must pay your
representative the authorized fee
directly, visit our Public Policy page at
http://www.ssa.gov/representation/
index.htm.
Note: Please use this replacement
language in all duplicate sections of the
screenshots to ensure consistency and
accuracy throughout the document.
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Fee Agreement for Representation Before the Social Security Ad...
Page 2 of 2
Form SSA-1693 (3/XX/2021)
Replace the privacy statement with the
updated language. "Section 206 and 1631(d)
of the Social Security Act, as amended, allow
us to collect this information, which we will
use to authorize fees for services rendered to
the claimant named on the form. Providing
the information is voluntary, but not
providing all or part of the information may
affect the amount of fees authorized for
services rendered before SSA. As law
permits, we may use and share the
information you submit, including with other
Federal agencies, contractors, and others, as
outlined in the routine uses within System of
Records Notices (SORN) 60-0003, 60-0089,
and 60-0325, available at www.ssa.gov/
privacy. The information you submit may
also be used in computer matching programs
to establish or verify eligibility for Federal
benefit programs and to recoup debts under
these programs. "
Note: Please use this replacement language in
all duplicate sections of the screenshots to
ensure consistency and accuracy throughout
the document.
•
•
•
•
•
•
•
•
we did not withhold past-due benefits,
your claim did not result in past-due benefits,
your representative is not eligible under our rules for direct payment of the fee from us,
your representative waived direct payment of the fee from us,
you ended the appointment of the representative before we issued a favorable decision,
your representative withdrew from representing you before we issued a favorable decision,
your representative was disqualified or suspended from acting as a representative before we issued the direct payment,
your representative did not submit a valid fee agreement before the first favorable decision in your claim or did not:
o ask for our approval of a fee with a fee petition until 60 days after the date of your notice of award, or
o timely tell us that he or she planned to ask for a fee with a fee petition.
II
Replace the deleted text with the new
language. "If you appoint multiple
representatives, all representatives who
provide representational services on your
claim and who do not waive a fee for
those services must sign on a single fee
agreement for the fee agreement to be
approved. They may use the last page for
this purpose."
Note: Please use this replacement
language in all duplicate sections of the
screenshots to ensure consistency and
accuracy throughout the document.
Electronic Signatures
If you agree to its terms, you and your representative(s) must electronically sign, date, and submit this form by selecting the
"Click to Sign" button. If you are appointing multiple representatives, all of your representatives who intend to ask for a fee for
services provided on your claim must sign on a single fee agreement for the fee agreement to be approved. Unlike the paper
version of this form, this on line version only allows for the signatures of up to six representatives. If you have appointed, or
intend to appoint, more than six representatives who want to charge and receive a fee for the services provided on your claim,
you cannot use this online version.
Privacy Act Statement - Collection and Use of Personal Information
Sections 206 and 1631(d) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this
information is voluntary. However, failing to provide all or part of the information may affect the amount of fees authorized for
services rendered before us.
We will use the information you provide to authorize fees for services rendered to the claimant named on the form. We may
also share your information for the following purposes, called routine uses:
•
To a claimant's representative to the extent necessary to dispose of a fee petition or fee agreement; except for pre
decisional deliberative documents, such as analyses and recommendations prepared for the decision-maker;
•
To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration
of its programs; and
•
To the Internal Revenue Service and to State and local government tax agencies in response to inquiries regarding receipt of
fees we paid directly starting in calendar year 2007.
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 Notices (SORN) 60-0003, entitled Attorney Fee
File, as published in the Federal Register (FR) on January 11, 2006, at 71 FR 1803; 60-0089, entitled Claims Folders System, as
published in the FR on October 31, 2009, at 84 FR 58422; and 60-0325, entitled Appointed Representative File, as published in
the FR on October 8, 2009, at 74 FR 51940. Additional information and a full listing of all our SORNs are available on our website
at www.ssa.gov/privacy.
Paperwork Reduction Act Statement
This information collection meets the clearance 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
and Budget (0MB) control number. We estimate that it will take about 7 minutes to read the instructions, gather the facts, and
answer the questions. You may send us comments on our time estimate to SSA, 6401 Security Boulevard, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
-V,
a,
References
• 18 U.S.C. §§ 203,205, and 207,
• 26 U.S.C. §§ 6041 and 6045(f)
• 42 U.S.C. §§ 406(a), 1320a-6, and 1383(d)2)
• 20 CFR §§ 404.1700 et seq. and 416.1500 et seq.
1'
Language I English: US
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Fee Agreement for Representation Before the Social Security Ad ...
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II
Replace the deleted text with the following
language: "Your dependents or auxiliary
Form SSA-1693 (3/XX/2021)
beneficiaries who do not have their own
Social Security Administration
0MB No. 0960-0810
representation will also be liable for a fee. This
form does not limit you and your representative(s)
from agreeing to any additional terms unrelated to
the fee. Requesting, receiving, or keeping a fee in
excess of the legal limit or in excess of what we
General lnfonnation
authorize is unlawful and may lead to sanctions for
your representative(s)."
You can use this online form to file electronically an agreement between you and your representative(s) to seek our
Note: Please use this replacement language in all
authorization of the fee your representative(s) may charge you for services your representative(s) provides before us. Section duplicate sections of the screenshots to ensure
206 of the Social Security Act limits the fee we authorize under a fee agreement to 25 percent of your past-due benefits or a consistency and accuracy throughout the document.
Fee Agreement for Representation Before the Social Security Administration
maximum dollar amount we set, whichever is less. This form does not limit you and your representative(s) from agreeing to any
additional terms unrelated to the fee. Requesting, receiving, or keeping a fee in excess of the legal limit or in excess of what we
authorize is unlawful and may lead to sanctions for your representative{s). Unless they have their own representation, your
dependents, spouse, or auxiliary beneficiaries will also be liable for a fee under this fee agreement if we approve benefits for
them. Unlike the paper version, this online form limits the total number of representatives who sign it to six.
Representative's Information
Start
,,.
Representative's Rep 10
!*____________________.
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*
First Name
[
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La,t Nam,
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Mailing Address
*
City
*
F
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Phone Number
IP/Po,tal Code
Alternate Phone Number (Optional)
*
Claimant's lnfonnation
Claimant's Social Security Number
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*First Name
Mailing Address
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City
ZIP/Postal Code
State
Phone Number
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Language I English: US
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Next required field
Fee Agreement for Representation Before the Social Security Ad...
II
Form SSA-1693 (3/XX/2021)
Social Security Administration
Replace the deleted text with the
following language: "Your dependents or
0MB No. 0960-0810
auxiliary beneficiaries who do not have
their own representation will also be
liable for a fee. This form does not limit
you and your representative(s) from
General lnfonnation
agreeing to any additional terms
unrelated to the fee. Requesting,
You can use this online form to file electronically an agreement between you and your representative(s) to seek our
receiving, or keeping a fee in excess of
authorization of the fee your representative(s) may charge you for services your representative(s) provides before us. Section
the legal limit or in excess of what we
206 of the Social Security Act limits the fee we authorize under a fee agreement to 25 percent of your past-due benefits or a
authorize is unlawful and may lead to
maximum dollar amount we set, whichever is less. T his form does not limit you and your representative(s) from agreeing to any sanctions for your representative(s)."
additional terms unrelated to the fee. Requesting, receiving, or keeping a fee in excess of the legal limit or in excess of what we
Note: Please use this replacement language in all
authorize is unlawful and may lead to sanctions for your representative{s). Unless they have their own representation, your
duplicate sections of the screenshots to ensure
dependents, spouse, or auxiliary beneficiaries will also be liable for a fee under this fee agreement if we approve benefits for
consistency and accuracy throughout the
document.
them. Unlike the paper version, this online form limits the total number of representatives who sign it to six.
Fee Agreement for Representation Before the Social Security Administration
Representative's Info rmation
Representative's Rep 10
I I
1 1234567890
l nmal L
First Name
Test
Mailing Address
Test Address
Phone N umber
Alternate Phone Number (Optional)
111-222-3333
Claimant's lnfonnation
I
First Name
Test
Initial Last Name
Claimant
Mailing Address
City
State
Phone Number
Saving_
Language I English: US
ZIP/Postal Code
] 11111
(111) 222-3333
Claimant's Social Security Number
Next
Nam,
State
j MD
City
Test
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Attemate Phone Number (Optional)
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Fee Agreement for Representation Before the Social Security Ad...
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z
ID
Next required field
Replace this language to read: "If SSA favorably
my claim(s) and the decision results in pastPage 2 ofdecides
2
Form SSA-1693 (3/XX/2021)
Standard Fee Agreement
Replace the deleted text with the
following language: "I agree to pay
the maximum fee as stated in the
preceding paragraph. By selecting
this box, I acknowledge my
representative has informed me of
the current maximum dollar amount
that I may have to pay and also that
SSA may increase the maximum
dollar amount before the date of my
favorable determination or decision."
Replace the deleted text with the following
new language:
"If my claim(s) proceeds beyond
the________________________________
__ level of review and results in a favorable
determination or decision due to that appeal
the fee agreement is void and my
representative(s) may seek a higher fee by
filing a fee petition. SSA must authorize
this fee."
Note: Please use this replacement language
in all duplicate sections of the screenshots
to ensure consistency and accuracy
throughout the document.
Replace the deleted text and
replace with the following
language: "Only representatives
who have been properly
appointed can be authorized to
receive under the fee agreement
process."
Note: Please use this replacement
language in all duplicate sections
of the screenshots to ensure
consistency and accuracy
throughout the document.
Add the following language
above the claimant's signature
line. "By signing this form, I
affirm all of the information
provided above and
acknowledge that I have been
informed of the maximum
dollar amount that I may have
to pay and also that SSA may
increase this maximum dollar
amount before the date of my
favorable determination or
decision. However, if this fee
agreement reflects that the
parties have agreed to a fee
that is less than the maximum
dollar amount, the agreed upon
lower amount will remain
applicable regardless of any
changes to the maximum dollar
amount."
If the Social Security Administration (SSA) favorably decides my claim(s) and the decision resuffs in past-due benefits, section
206(a)(2) of the Social Security Act permits me to agree to pay my representative(s) a fee that does not exceed the lesser of
25 percent of my past-due benefits or the maximum doflar amount set by the Commissioner of Social Security on the date
SSA authorizes my representative's fee. The maximum amount is $6,000 as of the publication of this form.
Choose One:
*o
*o
I agree to pay the maximum fee as stated in the preceding paragraph.
I agree to pay less than the maximum S
I
Language English: US
%.
or
due (retroactive) benefits, I agree to pay my
representative(s) a fee that does not exceed the lesser
of 25 percent of my past-due benefits or the
maximum dollar amount allowed under the Social
Security Act Section 206(a)(2), or such higher
amount set by the Commissioner of Social Security
based on the maximum dollar amount in effect as of
the date of my favorable determination. The current
maximum fee amount is available on the Pubic
Policy page on our website at htts://secure.ssa.gov/
apps10poms.nsf/lnx/0203920006."
Note: Please use this replacement language in all
duplicate sections of the screenshots to ensure
consistency and accuracy throughout the document.
I understand that I, my eligible spouse, any affected auxiliary beneficiary, my representative or the decision maker
have the right to protest the fee authorized under this fee agreement, in writing, within 15 days from the authorization.
I understand that my representative may still request a fee even if my case does not result in past-due benefits, or the decision
is not favorable. If the fee agreement cannot be approved because there are no past-due benefits or for other reasons, my
representative may file a fee petition to request that SSA authorize a fee. I also understand that if there are no past-due
benefits withheld, if not enough past-due benefits are withheld, or if my representative is not eligible for direct payment by
SSA, I will be responsible to pay the authorized fee to my representative directly. SSA is not responsible for authorizing out-of
pocket costs and expenses for which I may be responsible to pay directly to my representative.
Two-Tiered Fee Agreement (Optional)
Replace the deleted text with the following new
language: "I agree to pay less than the
maximum. I agree to pay the lesser of
$______or________%"
Note: Please use this replacement language in
all duplicate sections of the screenshots to
ensure consistency and accuracy throughout the
document.
Note: Please use this replacement language in
all duplicate sections of the screenshots to
ensure consistency and accuracy throughout the
document.
Only complete this section if you and your representative(s) have chosen to limit the effect of this fee agreement to a certain
administrative level.
Check only if applicable:
O
O
Q
Q
This fee agreement is in effect through this administrative level: Initial
Reconsideration
Hearing
NIA
I understand that a two-tiered fee agreement is not required, but if chosen and SSA favorably decides my claim(s) above the
administrative level indicated above, SSA will disapprove it and my representative(s) may ask SSA to authorize a fee by filing a
fee petition. Only complete this section if you and your representative have chosen to limit the effect of this fee agreement to a
certain appeal level.
Escrow!Trust Accounts or Third-Party Payments (Optional)
Only complete this section if your representative(s) will use an escrow or trust account, or someone other than you or your
spouse, dependents or auxiliary beneficiaries or another individual has or will pay your representative a fee.
Check only if applicable:
0
0
With my consent my representative(s) has/have or will establish an escrow/trust account in the amount of$ _______
My representative will receive a fee from another party (e.g., state, county, private entity) of$ --------and I will have no financial responsibility to pay any fee, unless SSA authorizes the total fee (i.e., the total amount paid by the
third party, me, and/or my spouse, dependents or auxiliary beneficiaries).
Claimant and Representative Signatures
Add a period after "total fee." and remove the
remaining text from the form.
Note: Please use this replacement language in
all duplicate sections of the screenshots to
ensure consistency and accuracy throughout
the document.
Only representative who have been properly appointed can be authorized to receive a fee. The claimant and any appointed
representative(s) not waiving a fee are each required to sign this fee agreement. Other representatives can also sign on the
form.
Add the following text above the representatives signature.
Claimant's Signature
Date
*Click here to sign
Jun 10, 2021
Representative's Signature
Date
1' W
Saved
II
4
--
/5
8
(±)
"By signing this form, I affirm all the information provided
above and acknowledge that I have informed the claimant of
the maximum dollar amount that they may have to pay and
also that SSA may increase this maximum dollar amount
before the date of the favorable determination or decision. I
will inform the claimant of any increase in the maximum
dollar amount that occurs before the date of the favorable
determination or decision. However, if this agreement reflects
that the parties have agreed to a fee that is less than the
maximum dollar amount, the agreed upon lower amount will
remain applicable regardless of any changes to the maximum
dollar amount."
Note: Please use this replacement language in all duplicate
sections of the screenshots to ensure consistency and accuracy
throughout the document.
.!,
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Form SSA-1693 (3/XX/2021)
Standard Fee Agreement
If the Social Security Administration (SSA) favorably decides my claim(s) and the decision resuffs in past-due benefits, section
206(a)(2) of the Social Security Act permits me to agree to pay my representative(s) a fee that does not exceed the lesser of
25 percent of my past-due benefits or the maximum doflar amount set by the Commissioner of Social Security on the date
SSA authorizes my representative's fee. The maximum amount is $6,000 as of the publication of this form.
See Prior page for revised edits.
Choose One:
0
See Prior page for revised language
I agree to pay the maximum fee as stated in the preceding paragraph.
@ I agree to pay less than the maximum S 100
or
See Prior page for revised edits.
%.
I understand that I, my eligible spouse, any affected auxiliary beneficiary, my representative or the decision maker
have the right to protest the fee authorized under this fee agreement, in writing, within 15 days from the authorization.
I understand that my representative may still request a fee even if my case does not result in past-due benefits, or the decision
is not favorable. If the fee agreement cannot be approved because there are no past-due benefits or for other reasons, my
representative may file a fee petition to request that SSA authorize a fee. I also understand that if there are no past-due
benefits withheld, if not enough past-due benefits are withheld, or if my representative is not eligible for direct payment by
SSA, I will be responsible to pay the authorized fee to my representative directly. SSA is not responsible for authorizing out-of
pocket costs and expenses for which I may be responsible to pay directly to my representative.
Two-Tiered Fee Agreement (Optional)
See previous page for revised
edits.
Only complete this section if you and your representative(s) have chosen to limit the effect of this fee agreement to a certain
administrative level.
Check only if applicable:
O
Q
Q
This fee agreement is in effect through this administrative level: Initial @ Reconsideration
Hearing
NIA
I understand that a two-tiered fee agreement is not required, but if chosen and SSA favorably decides my claim(s) above the
administrative level indicated above, SSA will disapprove it and my representative(s) may ask SSA to authorize a fee by filing a
fee petition. Only complete this section if you and your representative have chosen to limit the effect of this fee agreement to a
certain appeal level.
Escrow!Trust Accounts or Third-Party Payments (Optional)
Only complete this section if your representative(s) will use an escrow or trust account, or someone other than you or your
spouse, dependents or auxiliary beneficiaries or another individual has or will pay your representative a fee.
Check only if applicable:
r.i
0
See Prior page for revised
language
1oo
_
_
With my consent my representative(s) has/have or will establish an escrow/trust account in the amount of$_ _ ____
My representative will receive a fee from another party (e.g., state, county, private entity) of$ --------and I will have no financial responsibility to pay any fee, unless SSA authorizes the total fee (i.e., the total amount paid by the
third party, me, and/or my spouse, dependents or auxiliary beneficiaries).
Claimant and Representative Signatures
Only representative who have been properly appointed can be authorized to receive a fee. The claimant and any appointed
representative(s) not waiving a fee are each required to sign this fee agreement. Other representatives can also sign on the form.
See Prior page for revised
language
See Prior page for
revised language
Claimant's Signature
Test 'RetJ
�Rl'O OunKl.,2621)
Representative's Signature
Date
Jun 10, 2021
Date
Ill
By signing,/ agree to both this agreement and the l1.,,,,, •n,01 ,l 'C,1'>,Jt'. My use ofAdobe
Sign isgovemed by the -'1,1,,t,e Tc.01--0, ,,, ,/"'·
ct·ICktO s·Ign
See Prior page for revised
language
9
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Add the following text at the end of the
sentence: "By signing this agreement, I
affirm all of the information provided
above and acknowledge that I have
informed the claimant of the maximum
dollar amount that they may have to pay
and also that SSA may increase this
maximum dollar amount before the date of
the favorable determination or decision. I
will inform the claimant of any increase in
the maximum dollar amount that occurs
before the date of the favorable
determination or decision. However, if this
fee agreement reflects that the parties have
agreed to a fee that is less than the
maximum dollar amount, the agreed upon
lower amount will remain applicable
regardless of any changes to the maximum
dollar amount."
Fee Agreement for Representation Before the Social Security Ad...
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Form SSA-1693 (03/XX/21)
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Additional Signatures
This page is optional - Use only if multiple representatives want to sign on the same fee agreement.
Representative's Rep ID (when applicable)
Representative's Name and Signature
Ill
By signing, I agree to both this agreement and the l''">,, •n,0 1 ,l "·'.,,.re.My use ofAdobe
Sign isgovemed by the -",l,,t,e Tc0r--,, ,,,,/"'·
ct·ICktO s·Ign
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You have a document to review and sign. You can access the document using the link above. For additional security, the appointed
representative has set a password for this document. If you are not the appointed representative, you will need to contact the appointed
representative to get the password in order to review this document. If any of the information in the document is incorrect or if you
disagree with any of the information, the appointed representative should restart the process.
This link is personalized for you and, for security purposes, we recommend that you do NOT forward/share this email or link with others.
If you DO forward/share this email or link with others, you accept the risk that, by sharing your personal information, the person assisting
you may misuse your personal information. If you have any questions about this email or feel that you received this in error, please
contact SSA at 1-800-772-1213 (TTY 1-800-325-0778) between 8:00 am - 7:00 pm, Monday through Friday.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit https://oig.ssa.gov/report or call the Inspector General's Fraud Hotline at 1-800-2690271 (TTY 1-800-501-2101).
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Fonn SSA-1693 (3/XXl2021)
Social Security Administration
II
0MB No. 0960-0810
INSTRUCTIONS FOR COMPLETING FORM SSA-1693
See
Prior planned edits.
YOU DO NOT HAVE TO SIGN THIS FORM - Your appointed representative initiated this fonn online. Use and sign this fonn
only
if you agree to its tenns. If you do not agree, do not sign it Refusing to sign the fonn will not affect how we will process your
claim, or our future decisions about it. In this document, "you• me·ans the claimant, beneficiary, auxiliary, or spouse. In this
document, "us• and "SSA" means the Social Security Administration. Do not file fonn SSA-1693 unless you have appointed the
representative (e.g., filed an SSA-1696) for a claim or issue you have pending with us.
If you suspect Social Security F raud, please visit http:/loig.ssa.gov/report or call the Inspector General's Fraud Hotline
at 1-800-269-0271 (TTY 1-866-501-2101).
See Prior planned
edits.
See Prior planned edits.
See Prior planned edits.
Requesting a fee for representational services
Your appointed representative can ask for a fee for the services he or she provided in your claim. Not all representatives ask for a
fee, and some only charge a fee if they win your case. To charge you a fee, your representative(s) generally must get our
approval. Your representative can get our approval by submitting a fee agreement (you may use this fonn) or a fee petition. You
and your representative choose which of these two processes to use. Under the fee agreement process, the amount your
representative can ask for is limited by the Social Security Act Under the fee petition process, your representative can ask for a
higher fee. For more information on fees, fee processes, and our rules, visit our website at www.ssa.gov/representation.
Registration
Representatives who seek direct payment of their fee must first register with us. For more information on representative
registration, visit us online at www.ssa.gov/ar, contact us at 1-800-772-1213 (TTY 1-800-325-0778), or contact your local Social
Security office.
When t o file a fee agreement
Your representative(s) must file your fee agreement before we issue a favorable decision in your case. If you or your
representative(s) submit the fee agreement after our decision, we will disapprove your fee agreement
What you have to pay
Under the tenns of a fee agreement, you agree to pay an amount up to 25 percent of your total past-due benefits or an amount
set by us, whichever is less. You must pay the fee we authorize. Your spouse. dependents or your auxiliary beneficiaries will also
pay a fee unless they have their own representation. In addition to the fee we authorize, you may also have to pay:
• Fees authorized by a Federal court for services your attorney provided during court proceedings, and
• Any •out-of-pocket" expenses your representative may incur (e.g., costs for making copies of a doctor's or hospital's records).
Note: These fees and expenses do not require our authorization.
See Prior planned
edits.
Two-tiered fee agreements
You and your representative(s) should complete this field only if you want to limit the effect of this fee agreement to a certain
administrative level. If you choose this option and your case is appealed beyond the specified administrative level, your
representative(s) can file a fee petition. Under the fee petition process, the authorized fee may be higher than the amount
that can be authorized under the fee agreement process.
See Prior page for revised
edits.
Trust o r escrow accounts
See Prior page for revised
Your representative may accept money from you before we authorize a fee as long as he or she holds it in a trust or escrow
edits.
account according to our rules and policy. If you choose to enter into the trust or escrow agreement with your representative,
you may willingly deposit the money in the trust or escrow accournt and tell us on this form. Only complete this field if your
representative is using an escrow or trust account.
See Prior page for revised
edits.
Third-party payments
We collect infonnation on payments your representative may receive from a third party for services he or she provided to you
during the administrative proceedings. These fees may be in lieu of your fee payment, or may be in addition to your payment.
We may consider these payments during our authorization process to detennine if we need to authorize these fees under our
rules. All statutory and regulatory rules continue to apply in situations involving third-party payments.
--
V,
a,
Withholding of funds and direct payment to your representative
If your representative is eligible under our rules to receive an authorized fee directly from us out of your past-due benefits, we
See Prior planned edits.
usually withhold 25 percent of your past-due benefits for direct payment of that fee. However, you are responsible for paying
your representative the authorized fee if:
• the amount of the fee we approve is more than the amount held for you in a trust or escrow account, or more than the amount
we can pay to your representative from your past-due benefits.
--.v
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Fonn SSA-1693 (3/XX/2021)
•
•
•
•
•
•
•
•
we did not withhold past-due benefits,
your claim did not result in past-1Ji-o.zaz1 IS.J7EDT)
Jun 10, 2021
Representative's Signature
Date
See Prior planned
edits.
Saved
Language I English: US
1' '¥
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See Prior planned edits.
See Prior planned
edits.
Page 2 of 2
Standard Fee Agreement
If the Social Security Administration (SSA) favorably decides my claim(s) and the decision results in past-due benefits, section
206(a)(2) of the Social Security Act permits me to agree to pay my representative(s) a fee that does not exceed the lesser of
25 percent of my past-due benefrts or the maximum dollar amount set by the Commissioner of Social Security on the date
SSA authorizes my representative's fee. The maximum amount is $6,000 as of the publication of this form.
Choose One:
[] I agree to pay the maximum fee as stated in the preceding paragraph.
� I agree to pay less than the maximum S
100
-------
or
%.
I understand that I, my eligible spouse, any affected auxiliary beneficiary, my representative or the decision maker
have the right to protest the fee authorized under this fee agreement, in writing, within 15 days from the authorization.
I understand that my representative may still request a fee even if my case does not result in past-due benefits, or the decision
is not favorable. If the fee agreement cannot be approved because there are no past-due benefits or for other reasons, my
representative may file a fee petition to request that SSA authorize a fee. I also understand that if there are no past-due
benefits withheld, if not enough past-due benefits are withheld, or if my representative is not eligible for direct payment by
SSA, I will be responstble to pay the authorized fee to my representative directly. SSA is not responsible for authorizing out-of
pocket costs and expenses for which I may be responstble to pay directly to my representative.
Two-Tiered Fee Agreement (Optional)
See Prior planned edits.
Only complete this section if you and your representative(s) have chosen to limit the effect of this fee agreement to a certain
administrative level.
Check only if applicable:
This fee agreement is in effect through this administrative level: Initial@ Reconsideration O Hearing
NIAO
O
I understand that a two-tiered fee agreement is not required, but if chosen and SSA favorably decides my claim(s) above the
administrative level indicated above, SSA will disapprove it and my representative(s) may ask SSA to authorize a fee by filing a
fee petition. Only complete this section if you and your representative have chosen to limit the effect of this fee agreement to a
certain appeal level.
Escrow/Trust Accounts or Third-P arty Payments (Optional)
Only complete this section if your representative(s) will use an escrow or trust account, or someone other than you or your
spouse, dependents or auxiliary beneficiaries or another individual has or will pay your representative a fee.
Check only if applicable:
121
D
See Prior planned edits.
_ _0____
With my consent my representative(s) has/have or will establish an escrow/trust account in the amount of$ _1 0
My representative will receive a fee from another party (e.g., state, county, private entity) of$ ________
and I will have no financial responsibility to pay any fee, unless SSA authorizes the total fee (i.e., the total amount paid by the
third party, me, and/or my spouse, dependents or auxiliary beneficiaries).
See Prior planned edits.
Claimant and Representative Signatures
See Prior planned
edits.
Onfy representative who have been properly appointed can be authorized to receive a fee. The claimant and any appointed
representative(s) not waiving a fee are each required to sign this fee agreement. other representatives can also sign on the form.
�Cbm
[EXTERNAL) Social Security Administration Has Sent You Fee Agreement for Representation Before the Social Security Administration
To
Additional Rep Email Address
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Delete_7_Year_Default (7 years)
8 If there are problems with how this message is displayed, click here to view it in a web browser.
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'.
Social Security Administration requests your signature
Fee Agreement for Representation Before the Social Security Administration
Form Expires On June 14, 2021
Review and sign
THIS LINK EXPIRES IN TEN (10) CALENDAR DAYS.
You have a document to review and sign. You can access the document using the link above. For additional security, the appointed
representative has set a password for this document. If you are not the appointed representative, you will need to contact the appointed
representative to get the password in order to review this document. If any of the information in the document is incorrect or if you
disagree with any of the information, the appointed representative should restart the process.
This link is personalized for you and, for security purposes, we recommend that you do NOT forward/share this email or link with others.
If you DO forward/share this email or link with others, you accept the risk that, by sharing your personal information, the person assisting
you may misuse your personal information. If you have any questions about this email or feel that you received this in error, please
contact SSA at 1-800-772-1213 (TTY 1-800-325-0778) between 8:00 am - 7:00 pm, Monday through Friday.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit https://oig.ssa.gov/report or call the Inspector General's Fraud Hotline at 1-800-2690271 (TTY 1-800-501-2101).
SOCIAL SECURITY ADMINISTRATION
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Fonn SSA-1693 (3/XXl2021)
Social Security Administration
II
0MB No. 0960-0810
INSTRUCTIONS FOR COMPLETING FORM SSA-1693
See Prior planned
edits.
YOU DO NOT HAVE TO SIGN THIS FORM - Your appointed representative initiated this fonn online. Use and sign this fonn only
if you agree to its tenns. If you do not agree, do not sign it Refusing to sign the fonn will not affect how we will process your
claim, or our future decisions about it. In this document, "you• means the claimant, beneficiary, auxiliary, or spouse. In this
document, "us• and "SSA" means the Social Security Administration. Do not file fonn SSA-1693 unless you have appointed the
representative (e.g., filed an SSA-1696) for a claim or issue you have pending with us.
See Prior planned
edits.
See Prior planned edits.
See Prior planned
edits.
-
V,
a,
If you suspect Social Security Fraud, please visit http:/loig.ssa.gov/report or call the Inspector General's Fraud Hotline
at 1-800-269-0271 (TTY 1-866-501-2101).
See Prior planned
edits.
Requesting a fee for representational services
Your appointed representative can ask for a fee for the services he or she provided in your claim. Not all representatives ask for a
fee, and some only charge a fee if they win your case. To charge you a fee, your representative(s) generally must get our
approval. Your representative can get our approval by submitting a fee agreement (you may use this fonn) or a fee petition. You
and your representative choose which of these two processes to use. Under the fee agreement process, the amount your
representative can ask for is limited by the Social Security Act. Under the fee petition process, your representative can ask for a
higher fee. For more information on fees, fee processes, and our rules, visit our website at www.ssa.gov/representation.
Registration
Representatives who seek direct payment of their fee must first register with us. For more information on representative
registration, visit us online at www .ssa.gov/ar, contact us at 1-800-772-1213 (TTY 1-800-325-0778), or contact your local Social
Security office.
When t o file a fee agreement
Your representative(s) must file your fee agreement before we issue a favorable decision in your case. If you or your
representative(s) submit the fee agreement after our decision, we will disapprove your fee agreement
What you have t o pay
Under the tenns of a fee agreement, you agree to pay an amount up to 25 percent of your total pa.st-due benefits or an amount
set by us, whichever is less. You must pay the fee we authorize. Your spouse, dependents or your auxiliary beneficiaries will also
pay a fee unless they have their own representation. In addition to the fee we authorize, you may also have to pay:
• Fees authorized by a Federal court for services your attorney provided during court proceedings, and
• Any "out-of-pocket" expenses your representative may incur (e.g., costs for making copies of a doctor's or hospital's records).
Note: These fees and expenses do not require our authorization.
Two -tiered fee agreements
You and your representative(s) should complete this field only if you want to limit the effect of this fee agreement to a certain
administrative level. If you choose this option and your case is appealed beyond the specified administrative level, your
representative(s) can file a fee petition. Under the fee petition process, the authorized fee may be higher than the amount
See Prior
that can be authorized under the fee agreement process.
See Prior planned
planned edits.
edits.
Trust or escrow accounts
Your representative may accept money from you before we authorize a fee as long as he or she holds it in a trust or escrow
account according to our rules and policy. If you choose to enter into the trust or escrow agreement with your representative,
you may willingly deposit the money in the trust or escrow account and tell us on this form. Only complete this field if your
See Prior planned
representative is using an escrow or trust account.
edits.
Third-party payments
We collect infonnation on payments your representative may receive from a third party for services he or she provided to you
during the administrative proceedings. These fees may be in lieu of your fee payment, or may be in addition to your payment.
We may consider these payments during our authorization process to detennine if we need to authorize these fees under our
rules. All statutory and regulatory rules continue to apply in situations involving third-party payments.
See Prior planned
edits.
Withholding of funds and direct payment to your representative
If your representative is eligible under our rules to receive an authorized fee directly from us out of your past-due benefits, we
usually withhold 25 percent of your past-due benefits for direct payment of that fee. However, you are responsible for paying
your representative the authorized fee if:
• the amount of the fee we approve is more than the amount held for you in a trust or escrow account, or more than the amount
we can pay to your representative from your past-due benefits,
--.v
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Form SSA-1693 (3/XX/2021)
•
•
•
•
•
•
•
•
See Prior planned edits.
See Prior planned edits.
II
we did not withhold past-due benefits,
your claim did not result in past-etween you and your representative(s) to seek our
authorization of the fee your representative(s) may charge you for services your representative(s) provides before us. Section
206 of the Social Security Act limits the fee we authorize under a fee agreement to 25 percent of your past-due benefits or a
maximum dollar amount we set, whichever is less. This form does not limit you and your representative(s) from agreeing to any
additional terms unrelated to the fee. Requesting, receiving, or keeping a fee in excess of the legal limit or in excess of what we
authorize is unlawful and may lead to sanctions for your representative(s). Unless they have their own representation, your
dependents, spouse, or auxiliary beneficiaries will also be liable for a fee under this fee agreement if we approve benefits for
them. Unlike the paper version, this online form limits the total nlllmber of representatives who sign it to six.
Representative's Information
Representative's Rep ID
I 1234567890
First Name
Test
Mailing Address
Test Address
City
State
MD
Test
Phone Number
ZIP/Postal Code
11111
Alternate Phone Number (Optional)
111-222-3333
(111) 222-3333
Claimant's Information
Claimant's Social Security Number
1123456789
First Name
Initial Last Name
Test
Claimant
Mailing Address
Test Address
City
State
MD
Test
--
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Phone Number
ZIP/Postal Code
11111
Alternate Phone Number (Optional)
1112223333
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Page 2 of 2
FOffil SSA-1693 (3/XX/2021)
Standard Fee Agreement
If the Social Security Administration (SSA) favorably decides my c/aim(s) and the decision results in past-due benefits, section
206(a)(2) of the Social Security Act permits me to agree to pay my representative(s) a fee that does not exceed the lesser of
25 percent of my past-due benefrts or the maximum dollar amount set by the Commissioner of Social Security on the date
SSA authorizes my representative's fee. The maximum amount is $6,000 as of the publication of this form.
See Prior planned edits.
Choose One:
ID
See Prior planned
edits.
I agree to pay the maximum fee as stated in the preceding paragraph.
� I agree to pay less than the maximum S
100
-------
%.
or
I understand that I, my eligible spouse, any affected auxiliary beneficiary, my representative or the decision maker
have the right to protest the fee authorized under this fee agreement, in writing, within 15 days from the authorization.
I understand that my representative may still request a fee even if my case does not result in past-due benefits, or the decision
is not favorable. If the fee agreement cannot be approved because there are no past-due benefits or for other reasons, my
representative may file a fee petition to request that SSA authorize a fee. I also understand that if there are no past-due
benefits withheld, if not enough past-due benefits are withheld, or if my representative is not eligible for direct payment by
SSA, I will be responstble to pay the authorized fee to my representative directly. SSA is not responsible for authorizing out-of
pocket costs and expenses for which I may be responsible to pay directly to my representative.
Two-Tiered Fee Agreement (Optional)
See Prior planned edits.
Only complete this section if you and your representative(s) have chosen to limit the effect of this fee agreement to a certain
administrative level.
Check only if applicable:
This fee agreement is in effect through this administrative level: Initial@ Reconsideration O Hearing
NIAO
I understand that a two-tiered fee agreement is not required, but if chosen and SSA favorably decides my claim(s) above the
administrative level indicated above, SSA will disapprove it and my representative(s) may ask SSA to authorize a fee by filing a
fee petition. Only complete this section if you and your representative have chosen to limit the effect of this fee agreement to a
certain appeal level.
O
Escrow/Trust Accounts or Third-P arty Payments (Optional)
Only complete this section if your representative(s) will use an escrow or trust account, or someone other than you or your
spouse, dependents or auxiliary beneficiaries or another individual has or will pay your representative a fee.
Check only if applicable:
Ill
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With my consent my representative(s) has/have or will establish an escrow/trust account in the amount of$ _1 0
_ 0
_ ____
_
My representative will receive a fee from another party (e.g., state, county, private entity) of$ ________
and I will have no financial responsibility to pay any fee, unless SSA authorizes the total fee (i.e., the total amount paid by the
third party, me, and/or my spouse, dependents or auxiliary beneficiaries).
See Prior planned edits.
See Prior planned edits.
Claimant and Representative Signatures
Only representative who have been properly appointed can be authorized to receive a fee. The claimant and any appointed
representative(s) not waiving a fee are each required to sign this fee agreement. other representatives can also sign on the form.
See Prior planned
edits.
See Prior planned edits.
--
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Jun 10, 2021
Date
Claimant's Signature
Jun 10, 2021
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Date
Representative's Signature
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Representative's Rep ID (when applicable)
Representative's Name and Signature
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Representative's Rep ID (when applicable)
11234567890
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Thu 6/10/2021 3:28 Pl\1
SOCIAL SECURITY ADMINISTRATION
[EXTERNAL] Fee Agreement for Representation Before the Social Security Administration has been Signed and Filed
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Agreement Participants: Names of appointed representative, claimant and any additional representatives will appear here.
You can open the final agreement to review its activity history or download a copy for reference.
For additional security, the originating representative has set a password for this document. If you are not the representative, you will need to contact the
representative to get the password in order to review this document If any of the information in the document is incorrect or if you disagree with any of the
information, the originating representative should restart the process.
This link is personalized for you and, for security purposes, we recommend you do NOT forward/share this email or link with others. If you DO forward/share this
email or link with others, you accept the risk that, by sharing your personal information, the person assisting you may misuse your personal information. If you have
any questions about this email or feel that you received this in error, please contact SSA at 1-800-772-1213 (TTY 1-800-325-0778) between 8:00 am - 7:00 pm,
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Op en Agreement
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Agreement Participants: Names of appointed representative, claimant and any additional representatives will appear here.
You can open the final agreement to review its activity history or download a copy for reference.
For additional security, the originating representative has set a password for this document. If you are not the representative, you will need to contact the
representative to get the password in order to review this document If any of the information in the document is incorrect or if you disagree with any of the
information, the originating representative should restart the process.
This link is personalized for you and, for security purposes, we recommend you do NOT forward/share this email or link with others. If you DO forward/share this
email or link with others, you accept the risk that, by sharing your personal information, the person assisting you may misuse your personal information. If you have
any questions about this email or feel that you received this in error, please contact SSA at 1-800-772-1213 (TTY 1-800-325-0778) between 8:00 am - 7:00 pm,
Monday through Friday.
The agreement is fully executed. The Social Security Administration has control over the retention period for this agreement which determines the amount of time it
will be available for download from Adobe Sign. Adobe recommends that you save a local copy of this fully-executed agreement for your records.
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To
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Op en Agreement
The agreement is complete.
Agreement Participants: Names of appointed representative, claimant and any additional representatives will appear here.
You can open the final agreement to review its activity history or download a copy for reference.
For additional security, the originating representative has set a password for this document. If you are not the representative, you will need to contact the
representative to get the password in order to review this document If any of the information in the document is incorrect or if you disagree with any of the
information, the originating representative should restart the process.
This link is personalized for you and, for security purposes, we recommend you do NOT forward/share this email or link with others. If you DO forward/share this
email or link with others, you accept the risk that, by sharing your personal information, the person assisting you may misuse your personal information. If you have
any questions about this email or feel that you received this in error, please contact SSA at 1-800-772-1213 (TTY 1-800-325-0778) between 8:00 am - 7:00 pm,
Monday through Friday.
The agreement is fully executed. The Social Security Administration has control over the retention period for this agreement which determines the amount of time it
will be available for download from Adobe Sign. Adobe recommends that you save a local copy of this fully-executed agreement for your records.
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Fee Agreement for Representation Before
the Social Security Administration
Created Sep 27, 202111:42 AM
From: Social Security Administration
([email protected])
Status: Signed
Message: THIS LINK EXPIRES IN TEN (10)
CALENDAR DAYS. You have a document to
review and sign. You can access the
document using the link above. For additional
security, the originating representative has set
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Fee Agreement for Representation Before
Form SSA-1693-APP (06-2021)
Social Security Administration
0MB No. 0960-0810
INSTRUCTIONS FOR COMPLETING FORM SSA-1693
the Social Security Administration
Created Sep 27, 2021 11:42 AM
See Prior planned edits.
From: Social Security Administration
( eform passworda [email protected])
We will email ou a link to download and save a co of the com leted form for our records.
YOU DO NOT HAVE TO SIGN THIS FORM - Your appointed representative initiated this form online. Use and sign this form only
if you agree to its terms. If you do not agree, do not sign it. Refusing to sign the form will not affect how we will process your
claim, or our future decisions about it. In this document, "you" means the claimant, beneficiary, auxiliary, or spouse. In this
document, "us" and "SSA" means the Social Security Administration. Do not file form SSA-1693 unless you have appointed the
representative (e.g., filed an SSA-1696) for a claim or issue you have pending with us.
Status: Signed
Message: THIS LINK EXPIRES IN TEN (10)
CALENDAR DAYS. You have a document to
If you suspect Social Security Fraud, please visit http://oig.ssa.gov/report or call the Inspector General's Fraud
Hotline at 1-800-269-0271 (TTY 1-866-501-2101).
See Prior planned edits.
review and sign. You can access the
Requesting a fee for representational services
Your appointed representative can ask for a fee for the services he or she provided in your claim. Not all representatives ask for a
fee, and some only charge a fee if they win your case. To charge you a fee, your representative(s) generally must get our
approval. Your representative can get our approval by submitting a fee agreement (you may use this form) or a fee petition. You
and your representative choose which of these two processes to use. Under the fee agreement process, the amount your
representative can ask for is limited by the Social Security Act. Under the fee petition process, your representative can ask for a
higher fee. For more information on fees, fee processes, and our rules, visit our website at www.ssa.gov/representation.
Registration
See Prior planned edits.
Representatives who seek direct payment of their fee must first register with us. For more information on representative
registration, visit us online at www.ssa.gov/ar, contact us at 1-800-772-1213 (TTY 1-800-325-0778), or contact your local Social
Security office.
security, the originating representative has set
document using the link above. For additional
See more
Actions
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Po
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Add Notes
See Prior planned edits.
When to file a fee agreement
Your representative(s) must file your fee agreement before we issue a favorable decision in your case. If you or your
representative(s) submit the fee agreement after our decision, we will disapprove your fee agreement.
What you have to pay
Under the terms of a fee agreement, you agree to pay an amount up to 25 percent of your total past-due benefits or an amount
set by us, whichever is less. You must pay the fee we authorize. Your spouse, dependents or your auxiliary beneficiaries will also
pay a fee unless they have their own representation. In addition to the fee we authorize, you may also have to pay:
• Fees authorized by a Federal court for services your attorney provided during court proceedings, and
• Any "out-of-pocket" expenses your representative may incur (e.g., costs for making copies of a doctor's or hospital's records).
Note: These fees and expenses do not require our authorization.
>
3 Recipients (3 Completed)
>
Activity
See Prior planned edits.
Two-tiered fee agreements
You and your representative(s) should complete this field only if you want to limit the effect of this fee agreement to a certain
administrative level. If you choose this option and your case is appealed beyond the specified administrative level, your
representative(s) can file a fee petition. Under the fee petition process, the authorized fee may be higher than the amount
that can be authorized under the fee agreement process.
Trust or escrow accounts
Your representative may accept money from you before we authorize a fee as long as he or she holds it in a trust or escrow
account according to our rules and policy. If you choose to enter into the trust or escrow agreement with your representative,
you may willingly deposit the money in the trust or escrow account and tell us on this form. Only complete this field if your
representative is using an escrow or trust account.
Third-party payments
We collect information on payments your representative may receive from a third party for services he or she provided to you
during the administrative proceedings. These fees may be in lieu of your fee payment, or may be in addition to your payment.
We may consider these payments during our authorization process to determine if we need to authorize these fees under our
rules. All statutory and regulatory rules continue to apply in situations involving third-party payments.
Withholding of funds and direct payment to your representative
If your representative is eligible under our rules to receive an authorized fee directly from us out of your past-due benefits, we
usually withhold 25 percent of your past-due benefits for direct payment of that fee. However, you are responsible for paying
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Form SSA-1693-APP (06-2021)
•
•
•
•
•
•
•
•
we did not withhold past-due benefits,
your claim did not result in past-due benefits,
your representative is not eligible under our rules for direct payment of the fee from us,
your representative waived direct payment of the fee from us,
you ended the appointment of the representative before we issued a favorable decision,
your representative withdrew from representing you before we issued a favorable decision,
your representative was disqualified or suspended from acting as a representative before we issued the direct payment,
your representative did not submit a valid fee agreement before the first favorable decision in your claim or did not:
o ask for our approval of a fee with a fee petition until 60 days after the date of your notice of award, or
o timely tell us that he or she planned to ask for a fee with a fee petition.
See Prior planned edits.
Electronic Signatures
If you agree to its terms, you and your representative(s) must electronically sign, date, and submit this form by selecting the
"Click to Sign" button. If you are appointing multiple representatives, all of your representatives who intend to ask for a fee for
services provided on your claim must sign on a single fee agreement for the fee agreement to be approved. Unlike the paper
version of this form, this online version only allows for the signatures of up to six representatives. If you have appointed, or
intend to appoint, more than six representatives who want to charge and receive a fee for the services provided on your claim,
you cannot use this online version. See Prior planned edits.
Privacy Act Statement - Collection and Use of Personal Information
Sections 206 and 1631(d) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this
information is voluntary. However, failing to provide all or part of the information may affect the amount of fees authorized for
services rendered before us.
We will use the information you provide to authorize fees for services rendered to the claimant named on the form. We may
also share your information for the following purposes, called routine uses:
•
•
•
..
To a claimant's representative to the extent necessary to dispose of a fee petition or fee agreement; except for pre
decisional deliberative documents, such as analyses and recommendations prepared for the decision-maker;
To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration
of its programs; and
Fee Agreement for Representation Before
the Social Security Administration
Created Sep 27, 202111:42 AM
From: Social Security Administration
( eform passworda [email protected])
Status: Signed
Message: THIS LINK EXPIRES IN TEN (10)
CALENDAR DAYS. You have a document to
review and sign. You can access the
document using the link above. For additional
security, the originating representative has set
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Activity
To the Internal Revenue Service and to State and local government tax agencies in response to inquiries regarding receipt of
fees we paid directly starting in calendar year 2007.
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 Notices (SORN) 60-0003, entitled Attorney Fee
File, as published in the Federal Register (FR) on January 11, 2006, at 71 FR 1803; 60-0089, entitled Claims Folders System, as
published in the FR on October 31, 2009, at 84 FR 58422; and 60-0325, entitled Appointed Representative File, as published in
the FR on October 8, 2009, at 74 FR 51940. Additional information and a full listing of all our SORNs are available on our website
at www.ssa.gov/privacy.
Paperwork Reduction Act Statement
This information collection meets the clearance requirements of 44 U.S.C. § 3507, as amended by Section 2 of the
Paperwork Reduction Act of 1995. Y ou do not need to answer these questions unless we display a valid Office of Management
and Budget (0MB) control number. We estimate that it will take about 7 minutes to read the instructions, gather the facts, and
answer the questions. You may send us comments on our time estimate to SSA, 6401 Security Boulevard, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
References
• 18 U.S.C. §§ 203, 205, and 207,
• 26 U.S.C. §§ 6041 and 6045(f)
• 42 U.S.C. §§ 406(a), 1320a-6, and 1383(d)2)
. .
.
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Fee Agreement for Representation Before
Form SSA-1693-APP (06-2021)
Social Security Administration
0MB No. 0960-0810
Fee Agreement for Representation Before the Social Security Administration
Ill
the Social Security Administration,
Created Jun 10, 2021 3:12 PM
From: Social Security Administration
See Prior planned edits.
General Information
(eform password [email protected])
Y ou can use this online form to file electronically an agreement between you and your representative(s) to seek our
authorization of the fee your representative(s) may charge you for services your representative(s) provides before us. Section
206 of the Social Security Act limits the fee we authorize under a fee agreement to 25 percent of your past-due benefits or a
maximum dollar amount we set, whichever is less. This form does not limit you and your representative(s) from agreeing to any
additional terms unrelated to the fee. Requesting, receiving, or keeping a fee in excess of the legal limit or in excess of what we
authorize is unlawful and may lead to sanctions for your representative(s). Unless they have their own representation, your
dependents, spouse, or auxiliary beneficiaries will also be liable for a fee under this fee agreement if we approve benefits for
them. Unlike the paper version, this online form limits the total number of representatives who sign it to six.
Status: Signed
Message: THIS LINK EXPIRES IN TEN (10)
CALENDAR DAYS. You have a document to
review and sign. You can access the
document using the link above. For additional
security, the originating representative has set
Representative's Information
I I;;:,•;
Representative's Rep ID
I 1234567890
Initial
First Name
Test
Mailing Address
See more
Actions
Name
Test Address
City
State
MD
Test
ZIP/Postal Code
11111
Alternate Phone Number (Optional)
Phone Number
(111) 222-3333
111-222-3333
�
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D ownload Audit Report
(;:I
Add Notes
>
3 Recipients (3 Completed)
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Activity
Claimant's Information
Claimant's Social Security Number
1123456789
Initial Last Name
First Name
Claimant
Test
Mailing Address
Test Address
City
State
Test
MD
11111
Alternate Phone Number (Optional)
Phone Number
1112223333
Q[00_3
Language I English: US
ZIP/Postal Code
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See Prior planned edits.
Form SSA-1693-APP (06-2021)
Page 2 of 2
Standard Fee Agreement
Ill
�
If the Social Security Administration (SSA) favorably decides my claim(s) and the decision results in past-due benefits, section
206(a)(2) of the Social Security Act permits me to agree to pay my representative(s) a fee that does not exceed the lesser of
25 percent of my past-due benefits or the maximum dollar amount set by the Commissioner of Social Security on the date
SSA authorizes my representative's fee. The maximum amount is $6,000 as of the publication of this form.
Choose One:
See Prior planned edits.
D
I agree to pay the maximum fee as stated in the preceding paragraph.
1ZiJ
I agree to pay less than the maximum$ 100
or
Fee Agreement for Representation Before
the Social Security Administration,
Created Jun 10, 2021 3:12 PM
From: Social Security Administration
([email protected])
Status: Signed
Message: THIS LINK EXPIRES IN TEN (10)
%.
See Prior planned edits.
I understand that I, my eligible spouse, any affected auxiliary beneficiary, my representative or the decision maker
have the right to protest the fee authorized under this fee agreement, in writing, within 15 days from the authorization.
I understand that my representative may still request a fee even if my case does not result in past-due benefits, or the decision
is not favorable. If the fee agreement cannot be approved because there are no past-due benefits or for other reasons, my
representative may file a fee petition to request that SSA authorize a fee. I also understand that if there are no past-due
benefits withheld, if not enough past-due benefits are withheld, or if my representative is not eligible for direct payment by
SSA, I will be responsible to pay the authorized fee to my representative directly. SSA is not responsible for authorizing out-of
pocket costs and expenses for which I may be responsible to pay directly to my representative.
Two-Tiered Fee Agreement (Optional)
Only complete this section if you and your representative(s) have chosen to limit the effect of this fee agreement to a certain
administrative level.
See Prior planned edits.
Check only if applicable:
NIAO
This fee agreement is in effect through this administrative level: Initial@ ReconsiderationO Hearing
O
I understand that a two-tiered fee agreement is not required, but if chosen and SSA favorably decides my claim(s) above the
administrative level indicated above, SSA will disapprove it and my representative(s) may ask SSA to authorize a fee by filing a
fee petition. Only complete this section if you and your representative have chosen to limit the effect of this fee agreement to a
certain appeal level.
Escrow/Trust Accounts or Third-party Payments (Optional)
C ALENDAR DAYS. You have a document to
review and sign. You can access the
document using the link above. For additional
security, the originating representative has set
See more
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3 Recipients (3 Completed)
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Only complete this section if your representative(s) will use an escrow or trust account, or someone other than you or your
spouse, dependents or auxiliary beneficiaries or another individual has or will pay your representative a fee.
Check only if applicable:
IZI With my consent my representative(s) has/have or will establish an escrow/trust account in the amount of$ _10_ 0_ _____
D My representative will receive a fee from another party (e.g., state, county, private entity) of$ _________
and I will have no financial responsibility to pay any fee, unless SSA authorizes the total fee (i.e., the total amount paid by the
third party, me, and/or my spouse, dependents or auxiliary beneficiaries).
See Prior planned edits.
Claimant and Representative Signatures
Only representative who have been properly appointed can be authorized to receive a fee. The claimant and any appointed
representative(s) not waiving a fee are each required to sign this fee agreement. Other representatives can also sign on the form.
See Prior planned edits.
rwde4twu-:
Jun 10, 2021
Claimant's Signature See Prior planned edits.
Date
Test Claimant (Jun 10, 202115:24 EDT)
See Prior planned edits.
Representative's Signature
Date
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Language English: US
Jun 10, 2021
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© 2021 Adobe. All rights reserved.
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Form SSA-1693-APP (06-2021)
Fee Agreement for Representation Before
Page 3 of 3
the Social Security Administration,
Additional Signatures
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Created Jun 10, 2021 3:12 PM
This page is optional - Use only if multiple representatives want to sign on the same fee agreement.
Representative's Rep ID (when applicable)
Representative's Name and Signature
I 1234567890
Add Rep Name
See Prior planned
edits.
From: Social Security Administration
([email protected])
Status: Signed
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Message: THIS LINK EXPIRES IN TEN (10)
CALENDAR DAYS. You have a document to
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document using the link above. For additional
security, the originating representative has set
See more
Actions
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English: US
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Terms Consumer Disclosure Trust Cookie preferences
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THIS IS AN AUTOMATIC REPLY FROM AN UN MONITORED MAILBOX.
MESSAGES SENT TO THIS MAILBOX ARE NOT REVIEWED AND ARE DELETED UPON RECEIPT.
Lost or forgotten password?
If you are not the representative, please contact the representative to obtain the password.
If you are the representative and have lost or forgotten the password you established, the password cannot be reset. You will need to start a new form.
To start a new form, visit:
SSA-1696 C laimant's Appointment of Representative
SSA-1693 Fee Agreement for Representation Before the Social Security Administration
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Tell us at www.ssa.gov/feedback.
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Mon 9/27/2021 12:23 PM
| File Type | application/pdf |
| File Modified | 2024-09-26 |
| File Created | 2021-05-17 |