Appointment of Representative

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Form SSA-1696-SUP2 (XX-2026)

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OMB No. 0960-0527

Social Security Administration

Instructions for Completing Form SSA-1696-SUP2
Keep a copy of this form for your records
In this document, “you” means the representative. “Us”, “we”, and “SSA” means the Social Security Administration.
General Information About This Form
This form is optional. Complete it only when applicable.
Withdrawal of a Representative
If you wish to withdraw your acceptance of the appointment, you must sign and date the withdrawal and file it with us either
in-person at the claimant’s local field office, or by electronic upload, mail, or fax. You should also tell the claimant. Your
withdrawal will take effect on the date we receive the signed document. Under our Rules of Conduct and Standards of
Responsibility for Appointed Representatives, representatives should withdraw representation only at a time and in a manner
that does not disrupt the processing or adjudication of a claim and allows the claimant adequate time to find new
representation, if desired. Once a hearing has been scheduled, a representative should not withdraw his or her representation
unless “extraordinary circumstances” exist (20 CFR §§ 404.1740(b)(3)(iv), 416.1540(b)(3)(iv)). Some examples of
“extraordinary circumstances” include a serious illness of the representative, a death or serious illness in the representative’s
immediate family, or failure to locate the claimant who is being represented in the particular action, despite active and diligent
attempts to contact the claimant. We will make determinations on whether a representative has withdrawn in a disruptive
manner on a case-by-case basis. However, if another representative replaces the representative who is seeking to withdraw
and there is no impact on the hearing process, we will not consider the withdrawal disruptive. While we will not prevent a
representative from withdrawing, if we determine the representative has withdrawn in a disruptive manner, we may pursue
sanctions against the representative.
Your withdrawal does not affect your eligibility for a fee or direct payment of a fee. Check the appropriate box to indicate whether
you intend to seek a fee via a fee agreement, you intend to seek a fee via a fee petition, you intend to waive your fee, or you have
already waived your fee.
You must submit your fee agreement to us before the date of the first favorable determination or decision on the claim. There is
no time limit for filing a fee petition. However, if you are seeking direct payment of a fee with a fee petition, you must submit the
petition, or notify us of your intent to do so, within 60 days after the date we mail the notice of the first favorable determination or
decision.
Before we recognize your waiver of fees, you must rescind any existing assignment of direct payment of those fees to an eligible
affiliated entity. To rescind an existing assignment, you must submit an updated Form SSA-1696 before the date we notify the
claimant of the first favorable determination or decision in their case.
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 verify
the claimant’s appointment and document your withdrawal. 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.
• 20 CFR §§ 404.1740(b)(2)(iv) and 416.1540(b)(2)(iv).

Formatted: Highlight

Form SSA-1696-SUP2 (XX-2026)

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Representative's Withdrawal of Acceptance of an Appointment
You, the representative, can stop working for the claimant. Complete all of the sections below, sign and date the form, and submit it
to one of our offices. Do not forget to enter the claimant’s Social Security Number and your Rep ID.

Representative's Information
Representative's Rep ID

Representative's First Name

Initial Last Name

Representative's Address

City

State

ZIP/Postal Code

State

ZIP/Postal Code

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

Claimant's First Name

Initial Last Name

Claimant's Address

City

I am withdrawing from this appointment.
I am seeking a fee and have filed or will file a fee agreement
I am seeking a fee and have filed or will file a fee petition
I was seeking a fee, but I hereby waive my fee
I previously waived my fee
Representative's Signature

Date