Instructions for Completing Form SSA-1696-SUP1

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OMB No. 0960-0527

Form SSA-1696-SUP1 (XX-2026)
Social Security Administration

Instructions for Completing Form SSA-1696-SUP1
Keep a copy of this form for your records
In this document, “you” means the claimant, beneficiary, auxiliary beneficiary, or spouse. “Us”, “we”, and “SSA” means the Social
Security Administration.
General Information About This Form
This form is optional. Complete it only when applicable.
Revocation of a Representative’s Appointment
You may use this form to revoke (end) an appointed representative’s authority at any time during the processing of your claim.
You must sign and date your revocation and file it with us, either in-person at one of our offices, or by electronic upload, mail, or
fax. You can find your local office at www.ssa.gov/locator. You should also tell your representative. Your revocation will take effect
on the day we receive the signed and dated document. After that, we will no longer deal with the named representative. If you
have no other representatives, you may continue your claim without a representative or appoint a new representative. If the
individual you revoke is your principal representative and you still have other appointed representatives, you must give us the
name of your new principal representative.
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, which we will use to v erify
the appointment of your representative and document your revocation. Providing this information is voluntary but not providing all
or part of the information may prevent us from assisting you with the request. 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 60-0089, 60-0320, and 60-0325, available at www.ssa.gov/privacy. The information you submit may
also be used in computer matching programs for Federal benefits eligibility or to recoup debts under these programs.
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 control number. We estimate that it will take about 5 minutes to read the instructions, gather the facts, and answer
the questions. You may send us your comments on our estimated completion time to SSA, Office of Disability Policy, 6401
Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.
References
• 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq.

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Form SSA-1696-SUP1 (XX-2026)

Claimant's Revocation of the Appointment of a Representative
You, the claimant, can stop your representative from working on your behalf. Complete, sign, and date the form below and submit
it to one of our offices. Use a separate form for each appointment you want to revoke. Do not forget to enter your Social Security
Number and your representative’s identification number (Rep ID), if you know it.

Claimant's Information
Claimant's Social Security Number
_
_
Claimant's First Name

Initial Last Name

Claimant's Address

State

City

ZIP/Postal Code

Representative's Information
Representative's Rep ID

I revoke the appointment of a representative that I previously appointed. I understand that this representative may be entitled to a
fee. The representative is:
Representative’s First Name
Initial Last Name

Complete If Necessary: This representative was my principal representative. I have appointed multiple
representatives, and I now name as my new principal representative:
Representative’s First Name
Initial Last Name

Representative's Address

City

Claimant's Signature

State

ZIP/Postal Code

Date