Form SSA-1691 Eligible Non-Attorney Representative

Form SSA-1691 (04-2025)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0699

Application to Participate in the Eligible For
Direct Payment Non-Attorney Representative Program
In this document, “you” means the non-attorney applicant. “Us,” “we” and “SSA” means the Social Security Administration.
General information about this form
The purpose of this form is to collect your information, which we will review and determine whether you qualify to take the
examination, participate in the program, and act as an eligible for direct payment non-attorney (EDPNA). You must complete this
application carefully and provide all supporting documentation as required. You must mail a completed and signed form to the
administrator of the EDPNA program. You can find the administrator’s mailing address and any other information about the
EDPNA program by going to our Representing Social Security Claimants website at
http://www.ssa.gov/representation/nonattyrep.htm.
Attorneys who have fees paid directly from their clients' past-due benefits pursuant to section 206 of the Social Security Act (the
Act) are not required to take the examination. Attorneys who are suspended or disbarred by a State or Federal court or
disqualified from appearing before a Federal agency or program are not eligible to receive direct payment and should not submit
an application.
Application fee
The Commissioner may assess applicants a reasonable fee to cover the costs of administering the application. Visit http://
www.ssa.gov/representation/nonattyrep.htm to find out where to pay this fee and other guidelines about this application fee.
If you fail the examination, or we find you ineligible to take the examination because you do not meet the educational
requirement, you may reapply in a future application period, but must pay the full fee again.
Examination
You are required to pass an examination testing your knowledge of the relevant provisions of the Act and the most recent
changes in Agency regulations and court decisions affecting Titles II and XVI of the Act. The examination should be held online
only. For more information about the details of the examination, visit http://www.ssa.gov/representation/nonattyrep.htm
Instructions for completing this form
This form is available in fillable PDF form during the application period at http://www.ssa.gov/representation/nonattyrep.htm.
If you are using a printed copy, type or print legibly using only a blue or black ink pen. Complete all sections. If you need to
provide additional information, attach an supplementary page.
Section 1 – Applicant’s Information
Complete all the information, including your name, Social Security Number, date of birth, and contact information.
Section 2 – Educational or Equivalent Professional Work Experience Information
Complete only the applicable information.
You must possess either (1) a bachelor’s degree from an accredited U.S. postsecondary institution or (2) four years of relevant
professional experience that we determine to be equivalent to a bachelor’s degree, plus either a high school diploma or general
equivalency diploma (GED). You must meet these requirements prior to the date the application period begins. We will consider
relevant professional experience for the EDPNA program to be four years of full time work, or the equivalent, through which the
applicant reviewed and analyzed medical reports and demonstrated the ability to describe and assess mental or physical
limitations. We will also continue to consider relevant professional experience to include work involving claims for benefits under
title II or XVI of the Act. Types of work that may qualify as relevant professional experience may be in fields such as teaching,
counseling or guidance, social work, personnel management, public employment service, nursing, or health care professions
when that experience meets the requirements above.
You must send proof of your educational qualifications after you pass the examination. Failure to do so precludes you from
establishing your eligibility to receive direct payment of fees. Visit http://www.ssa.gov/representation/nonattyrep.htm for types of
acceptable proof.

Form SSA-1691 (04-2025)

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Section 3 – Disqualification
Respond to all statements and provide relevant information as it applies.
Section 4 – Reasonable Accommodation Request
Use this section to describe your need for reasonable accommodation while participating in the examination. You must provide
supporting documentation from a qualified health professional. Visit https://www.ssa.gov/representation/nonattyrep.htm for more
information.
Section 5 – Signatures
Read and initial the statements before signing the form below the perjury statement.
Section 6 – Criminal Background Information
Complete all fields. If you do not pass our criminal background check or if you provide us with false or misleading information, we
will find you ineligible for direct payment.

Privacy Act Statement Collection and Use of Personal Information
Section 206(e) of the Social Security Act, as amended, allows us to collect this information. Furnishing us this information is
voluntary. However, failing to provide all or part of the information may prevent us from determining your eligibility for direct
payment.
We will use the information to determine your eligibility for direct payment. We may also share your information for the following
purposes, called routine uses:
• To contractors and other Federal agencies, as necessary, to assist us in efficiently administering our programs. We will
disclose information under this routine use only in situations in which we may enter into a contractual or similar agreement
with a third party to assist in accomplishing an agency function relating to this system of records; and
• To student volunteers, persons working under a personal services contract, and others who are not technically Federal
employees, when they are performing work for us, as authorized by law, and they need access to information in our records
in order to perform their assigned duties.
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 Notice (SORN) 60-0325, entitled Appointed
Representative File, as published in the Federal Register (FR) on October 8, 2009, at 74 FR 51940. Additional information, and a
full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.
Paperwork Reduction Act Statement
This information collection meets the 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 Budget control number.
We estimate that it will take 45 minutes to read the instructions, gather the facts, and answer the questions. Send only comments
relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to
our time estimate to this address, not the completed form.

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Application to Participate in the Eligible For
Direct Payment Non-Attorney Representative Program

Section 1 - Applicant's Information
First Name

Full Middle Name

Last Name

Suffix

Other Names Used

SSN

Date of Birth (mm/dd/yyyy)

Citizenship status
U.S. Citizen

Naturalized Citizen

Permanent U.S. Resident

Non-Resident with Employment Authorization
Document

Mailing Address
City

State

Preferred Email Address

Alternate Email Address

Phone Number

Area Code

ZIP Code

Phone Number

Alternate Phone Number

Work Phone Number

Area Code

Area Code

Phone Number

Phone Number

Section 2 - Educational or Equivalent Professional Work Experience Information
U.S. accredited postsecondary degree received
You must possess either a bachelor's degree from an accredited U.S. college or university or a high school diploma or GED
certificate and equivalent qualifications derived from work experience.
Name of U.S. College or University
Attended from Date (mm/yyyy)

City

State

Attended to Date (mm/yyyy)

Degree granted
Yes

High School or GED certificate received (not required with postsecondary degree)
High School Diploma
City

GED Certificate
State

No

Date awarded (mm/yyyy)

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Section 2 - Educational or Equivalent Professional Work Experience Information - Continued
Relevant professional experience (not required with postsecondary degree)
SSA-related professional experience

Other professional experience

Position/Title

From Date (mm/dd/yyyy) To Date (mm/dd/yyyy)

Position Description

Name of Employer
Address of Employer
City

State

Zip Code
Employer Phone Number

Name of Supervisor
Other relevant professional experience (not required with postsecondary degree)
SSA-related professional experience

Area Code

Phone Number

Other professional experience

Position/Title

From Date (mm/dd/yyyy) To Date (mm/dd/yyyy)

Position Description

Name of Employer
Address of Employer
City
Name of Supervisor

State

Zip Code
Employer Phone Number
Area Code

Phone Number

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Section 3 - Disqualification

I am now or have been disqualified, sanctioned or suspended from participating in any Federal
program or appearing before the SSA or any other Federal Agency.
If Yes, provide Name of Program or Agency

Yes

No

Address of Program or Agency
City

State

Zip Code

Details of Disqualification, Sanction or Suspension

Date of Disqualification, Sanction or Suspension (mm/dd/yyyy)

Date of Reinstatement (mm/dd/yyyy)

I am now or have been disqualified, sanctioned or suspended from participating in any Federal
program or appearing before the SSA or any other Federal Agency.
If Yes, provide Name of Program or Agency

Yes

No

Address of Program or Agency
City

State

Zip Code

Details of Disqualification, Sanction or Suspension

Date of Disqualification, Sanction or Suspension (mm/dd/yyyy)
I have fraudulently used or misused any
Social Security Benefits

Yes

I have a record for felony conviction

Yes

Date of Reinstatement (mm/dd/yyyy)

I have a judgment or lien assessed against me
by a civil court for malpractice and/or fraud
I have violated Social Security program rules
No (e.g., rules regarding disclosure of evidence
or representative payee rules)
No

I have previously applied for the Social Security Administration Eligible for Direct payment Non-attorney
Representative examination. (If you were previously denied because of a failed background check,
you may not reapply again.)

Yes

No

Yes

No

Yes

No

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Section 4 - Reasonable Accommodation Request

Describe any reasonable accommodation(s) you will need. Please note that you must provide supporting documentation from a
professional qualified to determine your condition along with your application to the address indicated on the Representing Social
Security Claimants Website at http://www.ssa.gov/representation/.

I certify that I understand that I must provide written documentation to support my request for special accommodations along with
this application.
Section 5 - Acknowledgments and Signature
If I cannot substantiate the statements made in my application or it is determined that the information I entered is
incorrect, I understand that I may be determined ineligible to sit for the examination or to receive direct payment of fees.
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly
gives a false statement about a material fact in this information, or causes someone else to do so, commits a crime and
may be subject to a fine or imprisonment.
Date (mm/dd/yyyy)
Signature

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Criminal Background Information

I authorize SSA to conduct a criminal background check so SSA may secure any criminal history information pertaining to me that
may be in the files of any Federal, State, or Local criminal justice agency. I authorize any Federal, State, or Local criminal justice
agency to release to SSA any criminal history information pertaining to me that may be in the agency's files. I authorize SSA, and
any of its agents, to disclose orally and in writing the results of this criminal background check to the business entity that
manages the information for managing direct payment eligibility for non-attorney representatives.
I understand that the results of the criminal background check may be used by SSA to determine my eligibility to sit for the
examination and receive direct payment, and may not otherwise be used except as authorized by law. In the event that SSA uses
information from the criminal background check, in whole or in part, in making an adverse decision with regard to my eligibility to
sit for the examination or to receive direct payment, I understand that SSA will provide me a copy of the report on the criminal
background check submitted by SSA and a description in writing of my right to protest the decision to SSA.
I understand that submission of this authorization is voluntary. I also understand that failure to provide the authorization and
information required to conduct a criminal background check will cause SSA to deny my application.
I understand that copies of this authorization that show my signature are as valid as the original, and that this authorization is
valid for 6 months from the date signed.
First Name

Middle Name

Last Name

Date of Birth (mm/dd/yyyy)

Place of Birth

SSN

Sex

Race

List of addresses for the last five years
Current address

City, State, Zip Code

From date (mm/yyyy) to present

Previous address

City, State, Zip Code

From date (mm/yyyy) to date (mm/yyyy)

Previous address

City, State, Zip Code

From date (mm/yyyy) to date (mm/yyyy)

Previous address

City, State, Zip Code

From date (mm/yyyy) to date (mm/yyyy)

Previous address

City, State, Zip Code

From date (mm/yyyy) to date (mm/yyyy)

Signature

Date (mm/dd/yyyy)

Daytime Phone Number
Area Code

Phone Number