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Fonn SSA-1693 (31XX/2021)
Social Security Administration
II
0MB No. 0960-0810
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 must first 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.
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.
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.
V,
a,
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
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Fee Agreement for Representation Before the Social Security Ad ...
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Form SSA-1693 (3/XX/2021)
Social Security Administration
II
0MB No. 0960-0810
Fee Agreement for Representation Before the Social Security Administration
General lnfonnation
You 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. As of 11/30/22, the maximum fee amount is $7,200. 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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Mailing Address
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*
IP/Po,tal Code
Alternate Phone Number (Optional)
Phone Number
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Claimant's lnfonnation
Claimant's Social Security Number
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First Name
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Mailing Address
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© 2021 Adobe. All rights reserved.
Terms Consumer Disclosure Trust Cookle preferences
fJ
Adobe Sign
Options v
Next required field
Fee Agreement for Representation Before the Social Security Ad...
Form SSA-1693 (3/XX/2021)
Social Security Administration
II
0MB No. 0960-0810
Fee Agreement for Representation Before the Social Security Administration
General lnfonnation
You 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. As of 11/30/22, the maximum fee amount is $7,200. T his 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
Representative's Rep 10
I I
1 1234567890
First Name
Test
lnmal
Mailing Address
Test Address
City
Test
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Phone Number
Claimant's lnfonnation
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First Name
Test
Initial Last Name
Claimant
Mailing Address
City
State
Phone Number
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Language I English: US
ZIP/Postal Code
] 11111
MD
(111) 222-3333
Claimant's Social Security Number
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Alternate Phone Number (Optional)
111-222-3333
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Attemate Phone Number (Optional)
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Fee Agreement for Representation Before the Social Security Ad...
Options v
z
ID
Next required field
II
Page 2 of 2
Form SSA-1693 (3/XX/2021)
Standard Fee Agreement
If SSA favorably decides my claim(s) and the decision results in past-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 date Social Security
Administration (SSA) authorizes my representative’ s fee.
Choose One:
*o
*o
I agree to pay the maximum fee as stated in the preceding paragraph ($7,200 as of November 30, 2022).
I agree to pay less than the maximum S
%.
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 responsible to pay the authorized fee to my representative directly. SSA is not responsible for authorizing out-ofpocket
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.
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
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.
Saved
Language I English: US
Claimant's Signature
Date
*Click here to sign
Jun 10, 2021
Representative's Signature
Date
1' W
4
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8
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Fee Agreement for Representation Before the Social Security Ad...
Required fields completed
Page 2 of 2
Form SSA-1693 (3/XX/2021)
Standard Fee Agreement
If SSA favorably decides my claim(s) and the decision results in past-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 date Social Security Administration (SSA) authorizes my representative’s fee.
Choose One:
0
I agree to pay the maximum fee as stated in the preceding paragraph ($7,200 as of November 30, 2022).
@ 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 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.
Check only if applicable:
Q
O
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.
o o_____
r.i With my consent my representative(s) has/have or will establish an escrow/trust account in the amount of$ _1_ _
Check only if applicable:
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).
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.
Claimant's Signature
Date
Test 'RetJ
Jun 10, 2021
�Rl'O OunKl.,2621)
Representative's Signature
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,
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Adobe Sign
Next Required
Fee Agreement for Representati. ..
Options v
Form SSA-1693 (3/XX/2021)
Social Security Administration
II
0MB No. 0960-0810
Fee Agreement for Representation Before the Social Security Administration
General lnfonnation
You 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. As of 11/30/22, the maximum fee amount is $7,200. 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
Representative's Rep ID
I 1234567890
First Name
Test
Mailing Address
Test Address
City
Test
State
MD
Phone Number
Alternate Phone Number (Optional)
111-222-3333
(111) 222-3333
ZIP/Postal Code
11111
Claimant's Information
Claimant's Social Security Number
Start
*
Initial Last Name
First Name
Test
Claimant
*
Mailing Address
*
City
State
*
Phone Number
Alternate Phone Number (Optional)
*
1' --.v
Language I English: US
*ZIP/Postal Code
3
IS
--
8
(±)
.!,
X
© 2021 Adobe. All rights reserved.
Terms Consumer Disclosure Trust Cookle preferences
fJ
Adobe Sign
Options v
Next Required
Fee Agreement for Representati...
Form SSA-1693 (3/XX/2021)
Social Security Administration
■
0MB No. 0960-0810
Fee Agreement for Representation Before the Social Security Administration
General lnfonnation
You 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. As of 11/30/22, the maximum fee amount is $7,200. 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
Representative's Rep ID
I 1234567890
First Name
Test
Mailing Address
Test Address
City
Test
State
MD
Phone Number
Alternate Phone Number (Optional)
111-222-3333
(111) 222-3333
ZIP/Postal Code
11111
Claimant's Information
Claimant's Social Security Number
I
1123456789
First Name
Initial Last Name
Test
Claimant
Mailing Address
Test Address
City
State
MD
Test
Next
Saved
Language I English: US
Phone Number
1112223333
ZIP/Postal Code
11111
Alternate Phone Number (Optional)
1' W
3
--
/5
8
(±)
J..
X
© 2021 Adobe. All rights reserved.
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Adobe Sign
Fee Agreement for Representati. ..
Options v
z
11)
Next Required
■
Page 2 of 2
FOffil SSA-1693 (3/XX/2021)
Standard Fee Agreement
If SSA favorably decides my claim(s) and the decision results in past-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 date Social Security Administration (SSA) authorizes my representative’s fee.
Choose One:
ID
I agree to pay the maximum fee as stated in the preceding paragraph ($7,200 as of November 30, 2022).
� 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)
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
NIAO
This fee agreement is in effect through this administrative level: Initial@ Reconsideration O Hearing
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:
Ill
D
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).
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.
Jun 10, 2021
Click here to sign
Saved
Language I English: US
Claimant's Signature
Date
Tfll R11>1Ji-o.zaz1 IS.J7EDT)
Jun 10, 2021
Representative's Signature
Date
1' '¥
4
--
/5
8
(±)
.!,
X
© 2021 Adobe. All rights reserved.
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Adobe Sign
Fee Agreement for Representati...
Options v
Required fields completed
Form SSA-1693 (3/XX/2021)
Page 2 of 2
Standard Fee Agreement
If SSA favorably decides my claim(s) and the decision results in past-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 date Social Security Administration (SSA) authorizes my representative’s fee.
Choose One:
[] I agree to pay the maximum fee as stated in the preceding paragraph ($7,200 as of November 30, 2022).
� 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)
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
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.
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 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).
Claimant and Representative Signatures
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.
�Cbmetween 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. As of 11/30/22, the maximum fee amount is $7,200. 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
I 1234567890
Representative's Rep ID
First Name
Test
Mailing Address
Test Address
City
State
MD
Test
Phone Number
Alternate Phone Number (Optional)
111-222-3333
(111) 222-3333
ZIP/Postal Code
11111
Claimant's Information
Claimant's Social Security Number
1123456789
First Name
Initial Last Name
Test
Claimant
Mailing Address
Test Address
City
State
MD
Test
-
Phone Number
ZIP/Postal Code
11111
Alternate Phone Number (Optional)
1112223333
V,
a,
1'
Language I English: US
w
3
--
Js
0
(±)
J..
X
© 2021 Adobe. All rights reserved.
Terms Consumer Disclosure Trust Cookle preferences
fJ
Adobe Sign
Next Required
Fee Agreement for Representati. ..
Options v
IJ
Page 2 of 2
FOffil SSA-1693 (3/XX/2021)
Standard Fee Agreement
If SSA favorably decides my claim(s) and the decision results in past-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 date Social Security Administration (SSA) authorizes my representative’s fee.
Choose One:
ID
I agree to pay the maximum fee as stated in the preceding paragraph ($7,200 as of November 30, 2022).
� 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)
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
D
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).
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.
Jun 10, 2021
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Claimant's Signature
Date
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Jun 10, 2021
Representative's Signature
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© 2021 Adobe. All rights reserved.
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� na2.documents.adobe.com/public/agreements/view/CBJCHBCAABAAF_RVTf1 qxjC1ur50VjQb512-4OWiA3Oh?type=esign&tsid=CBFCI...
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Form SSA-1693 (3/XX/2021)
Social Security Administration
Fee Agreement for Representation Before
the Social Security Administration ,
0MB No. 0960-0810
Fee Agreement for Representation Before the Social Security Administration
Created Jun 10, 2021 3:12 PM
From: Social S�curity Administration
General Information
(no-reply@)ssa.gov)
You 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. As of 11/30/22, the maximum fee amount is $7,200. 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
Representative's Rep ID
I 1234567890
First Name
Test
I I;;:,•;
Initial
See more
Actions
Name
Mailing Address
Test Address
State
City
MD
Test
Phone Number
111-222-3333
ZIP/Postal Code
11111
Alternate Phone Number (Optional)
(111) 222-3333
�
Download PDF
lfJ,
Download Audit Report
�
Add Notes
>
3 Recipients (3 Completed)
>
Activity
Claimant's Information
Claimant's Social Security Number
1123456789
First Name
Test
Initial Last Name
Claimant
Mailing Address
Test Address
City
Test
Phone Number
1112223333
State
MD
ZIP/Postal Code
11111
Alternate Phone Number (Optional)
...
Language
I English: US
© 2021 Adobe. All rights reserved.
Terms Consumer Disclosure Trust Cookie preferences
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II
Adobe Sign
Page 2 of 2
Form SSA-1693 (3/XX/2021)
••
•
Fee Agreement for Representation Before
the Social Security Administration,
Created Jun 10, 2021 3:12 PM
Standard Fee Agreement
If SSA favorably decides my claim(s) and the decision results in past-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 date Social Security Administration (SSA) authorizes my representative’s fee.
From: Social S�curity Administration
( no-reply@)ssa.gov)
Choose One:
l2lJ
8 Guest
Sign In
...
D
�
Status: Signed
I agree to pay the maximum fee as stated in the preceding paragraph ($7,200 as of November 30, 2022).
I agree to pay less than the maximum$ 100
or
Message: THIS LINK EXPIRES IN TEN (10)
%.
C ALENDAR DAYS. You have a document to
review and sign. You can access the
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.
document using the link above. For additional
security, the originating representative has set
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.
See more
Actions
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.
Check only if applicable:
NIAO
This fee agreement is in effect through this administrative level: Initial@ Reconsideration O 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)
�
Download PDF
�
Download Audit Report
�
Add Notes
>
3 Recipients (3 Completed)
>
Activity
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$ _1_00_ _____
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).
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.
rwc/e4twtt:
Jun 10, 2021
Claimant's Signature
Date
Test Claimant (Jun 10, 202115 :24 EDT)
Jun 10, 2021
Representative's Signature
Date
...
Language I English: US
© 2021 Adobe. All rights reserved.
Terms Consumer Disclosure Trust Cookie preferences
| File Type | application/pdf |
| File Modified | 2024-09-26 |
| File Created | 2021-05-17 |