Appointment of Representative

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Instructions for Completing Form SSA-1696
Keep a copy of this form for your records
DO NOT FILE FORM SSA-1696 IF YOU DO NOT HAVE A CLAIM WITH US, YOU ARE NOT FILING A CLAIM WITH THIS FORM, AND YOU HAVE NO
OTHER CASE OR ISSUE PENDING A DECISION WITH US. FILING THE FORM PREMATURELY WILL NOT EXPEDITE PROCESSING.

In this document, “you” means the claimant, beneficiary, auxiliary, or spouse. "We”, “us”, and “SSA” means the Social Security
Administration.
General Information About This Form
• You have the right to appoint a qualified representative of your choice to represent you on any claim or asserted right under any
of our programs. For more information on who can qualify to be an appointed representative, when your representative's
appointment begins or ends, payment of fees to appointed representative(s), and other helpful information, visit our website at
www.ssa.gov/representation. To locate your local field office, you can visit our website at www.ssa.gov/locator or call us,
toll-free, at 1-800-772-1213.
• You may also choose to be unrepresented. We will handle your case in the same manner whether you are represented or
unrepresented.
• You only need to appoint someone if they will be representing you (e.g., acting on your behalf or appearing before us on your
behalf). You do not need to appoint someone who simply helps you through the process. For example, a person who drives
you to our office, reads documents to you, or interprets for you if you speak another language does not need to be appointed.
• You and your representative(s) must give us accurate information as quickly as possible. Providing misleading or false
information on this form or on your application, or withholding or delaying giving us evidence, could lead to possible criminal
charges or administrative sanctions against you, or your representative, or both.
Appointing a Representative
You must use this form to appoint a representative. Complete Sections 1, 3, and 4 and enter your Social Security number in the
boxes provided at the top of each page after the first page. Your representative must follow the instructions below to complete
Sections 2, 5, 6, and 7, if appropriate, and must include their Representative ID at the top of each page. Both you and your
representative must sign the form in Section 8. Your representative or someone else can help you complete your sections, but
you must sign the form in Section 8. You or your representative must submit the completed form to us before we will recognize
your representative. You can electronically upload it, mail, fax, or eFax it to us or file it in-person at your local field office. Do not
file this form with your local State Disability Determination Services office. If you are appointing multiple representatives, use
separate forms for each representative.
Section 1 - Reason for Submission and Claimant's Information
To help us process this form, tell us why you are submitting it by checking all the boxes that apply in the "Reason for Submission"
section. If you or your representative want to change information you gave us before, check the "Update" box and any other
boxes that apply to what you are updating.
Provide your information, including your Social Security number. If you are filing your claim on someone else's Social Security
record, this person is the "number holder" and we need their information to process your claim.
Section 2 - Representative's Information
Your representative must complete the information in this section.
Section 3 - Claimant's Principal Representative
If you have more than one representative, use this section to name the person you want to be your principal representative. We
will communicate with and send notices to this person. If you choose a new principal representative, the person you chose before
will no longer be your principal representative but they will still be your representative unless you end their appointment. To end
their appointment, you must give us a separate writing or letter that you sign and date. You may also use the Form SSA-1696SUP1, Claimant’s Revocation of the Appointment of a Representative, to end a representative’s appointment.
Section 4 - Claim Type
Check all types of claims or issues before us for which you are appointing this representative.
Section 5 - Representative's Status, Affiliations, and Certifications
Part A - Representative's Status, Disqualifications, or Suspensions - Your representative must complete Part A to let us
know the representative's status as a professional.

Part B - Representative's Affiliation Information - If your representative is seeking direct payment of a fee and chooses to
designate an affiliate entity (business, firm, or other organization) for this claim, the representative must complete Part B and give
us the Employer Identification Number (EIN) of the affiliate entity. Before listing an entity in Part B, the entity must have registered
with us using Form SSA-1694, and the representative must have affiliated with the entity using Form SSA-1699. If your
representative does not want to designate an affiliate entity for this claim they should check "No EIN".
Part C - Assignment of Direct Payment of Authorized Fee to an Entity - If your representative wants us to pay any
representative fee we authorize directly to the entity identified as an affiliate in Part B, the representative must check the
"Assignment" box in Part C. We will send the appropriate tax forms to both the entity and the representative. For more information
on Forms IRS 1099-MISC and 1099-NEC, and employer registration, visit our website at www.ssa.gov/representation.
• If your representative wants to rescind (cancel) their prior assignment and make a new assignment to a different entity, they
must provide the information for the new entity in Part B of this section and check the “Assignment” box in Part C. A
representative may only assign direct payment to one entity for each claim. Making a new assignment on this form will
automatically rescind (cancel) any prior assignment your representative requested on a prior form.
• If your representative wants to rescind (cancel) their prior assignment to an entity and receive direct payment without
assigning to a new entity, they must check the “Rescission of prior assignment” box in Part C.
Part D - Representative's Certifications - Your representative must certify the accuracy of all statements in Part D.
Section 6 - Fee Arrangement
This section reflects you and your representative's agreement on payment of a fee, waiver of direct payment of a fee, or waiver of
a fee. Generally, to charge a fee for services, your representative must first get our approval. Your representative may waive
their right to charge you a fee or tell us that a third-party entity (business, government agency, or organization) will pay the fee. In
these situations, the third party must pay out of its own funds the fee and any expenses, and you and any auxiliary beneficiaries
(e.g., children or spouse) must be free of any responsibility to pay any fees or expenses.
Section 7 - Auxiliary Claimants
If auxiliary claimants, such as your children or spouse, have not appointed their own representative(s), you should list their names
and Social Security numbers in this section to help us accurately authorize fees and withhold funds to pay your representative in
their cases.
Section 8 - Signatures
If you are appointing a new representative, both you and your representative must sign the form in this section.
If you or your representative are submitting this form to update information relating to your existing appointment of this
representative:
• You must sign this form if you are updating the information in Section 3.
• Your representative must sign this form if updating the information in Section 5.
• Both you and your representative must sign this form if updating the information in Sections 4, 6, or 7.
To learn more about acceptable ways you can sign this form, please refer to our program rules or our Tips and Best Practices for
Appointed Representatives. You can find both on our Representing Claimants page at https://www.ssa.gov/representation/.
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 appointment of your representative and their acceptance of the appointment. 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 12 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, 6401 Security Blvd., 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; 42 U.S.C. §§ 406 and 1383(d)(2).
• 26 U.S.C. §§ 6041 and 6045(f) and 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq.

Form SSA-1696 (XX-2026) UF

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Claimant's Appointment of a Representative
Section 1 - Submission and Claimant's Information
Reason for Submission
Check the box indicating your reason for submitting this form. If you or your representative are submitting this form to update
information provided in a prior submission, please check the “Update” box and check the box(es) specifying the information you or
your representative are updating.
Appoint a new representative
Update information you previously submitted (Specify below by checking all applicable boxes)
Claimant's Principal Representative (Section 3)
Claim Type (Section 4)
Representative's Status, Disqualifications or Suspensions (Section 5, Part A)
Representative's Affiliation Information (Section 5, Part B)
Assignment of Direct Payment of Authorized Fee to an Entity (Section 5, Part C)
Fee Arrangement (Section 6)
Other Claimants (Section 7)
Claimant's Information
First Name

Initial Last Name

Claimant's Social Security Number

-

Number Holder's Information (Complete only when applicable)

My claim is based on another person’s work or earnings (e.g., spouse, parent). This person’s information is different from mine.
Number Holder's Social Security Number

-

-

First Name

Initial Last Name

Section 2 - Representative's Information
All representatives must register and receive a Representative Identification (Rep ID). For more information about registration
visit us on-line at www.ssa.gov/ar, contact us at 1-800-772-1213 (TTY 1-800-325-0778) or visit your local Social Security office. If
your representative wishes to update their registration information, they must do so using Form SSA-1699 Representative
Registration.
First Name
Registered Representative Rep ID

Initial Last Name

Form SSA-1696 (XX-2026) UF

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Claimant's Social Security Number
_
_

Representative's Rep ID

Section 3 - Claimant's Principal Representative (Complete only when applicable)
I have appointed more than one representative. The person named below is my principal representative. I ask SSA to
communicate with or send notices to this person. Any principal representative I named before is no longer my principal
representative but is still one of my representatives unless I have filed a separate writing revoking their appointment.
First Name

Initial Last Name

Section 4 - Claim Type
I appoint the individual named in Section 2 to act as my representative in connection with my claim(s) or asserted right(s) under
Title II (RSDI), Title XVI (SSI), Title XVIII (Medicare Coverage), and Title VIII (SVB) of the Social Security Act, as presently
amended, specifically for the issues identified below: (Check only those that apply)
Claim/Appeal for Title II Disability Benefits
Claim/Appeal for Title XVI Disability Benefits
Claim/Appeal for Title XVI Benefits
Claim/Appeal for Retirement Benefits
Claim/Appeal for Title XVIII (Medicare), VIII (Special Veteran's Benefits)
Continuing Disability Review (CDR)
Post-Entitlement Issue (A new issue you raise after you become eligible for benefits, such as an issue relating to your
benefit amount, your representative payee, suspension or termination of your benefits, or overpayment)

Section 5 - Representative's Status, Affiliations, and Certifications
Part A - Representative's Status, Disqualifications or Suspensions
(Representatives must always keep this information current)

I am an attorney (SSA rules state that a claimant may appoint an attorney in good standing who has the right to practice law
before a court of a State, Territory, District, or island possession of the United States, or before the Supreme Court or a
lower Federal court of the United States.)
I am a non-attorney eligible for direct payment (SSA rules require that non-attorneys meet certain criteria to qualify for direct
payment. See our website at www.ssa.gov/representation for the criteria.)
I am a non-attorney not eligible for direct payment
I am now or have previously been (check all that apply):
Suspended or Ddisqualified from participating in or appearing before SSA or any other a Ffederal program or agency.
If selected, explain:
Convicted of a violation under Section 206 or 1631(d) of the Social Security Act.
If selected, explain:
Disqualified from representing a claimant as a current or former officer or employee of the United States.
If selected, explain:
Disbarred or suspended from a court or bar to which I was previously admitted to practice law as an attorney.
If selected, explain:
Removed from practice or has/had any or all licenses suspended by a professional licensing authority or agency.
If selected, explain:

Form SSA-1696 (XX-2026) UF

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Claimant's Social Security Number
_
_

Representative's Rep ID

Part B - Representative's Affiliation Information
If you want to designate an affiliate entity (business, firm, or other organization) for this claim, provide the entity’s name and
Employer Identification Number (EIN) here. Before listing an affiliate entity, the entity must have registered with us using Form
SSA-1694, and you must have affiliated with the entity using Form SSA-1699. If you do not want to designate an affiliate entity
for this claim or do not qualify for or seek direct payment in this claim, you should check "No EIN".

EIN:

No EIN

Entity’s Name Enter the full name of the business, firm, or organization with which the representative wants to affiliate for this
claim.

Part C - Assignment of Direct Payment of Authorized Fee to an Entity
(Complete only when applicable)

Assignment - I, the representative whose name appears in Section 2 and whose signature appears in Section 8, request
any fee authorized to me in this claim be directly paid to the entity identified above in Part B. I understand that the entity to
which I assign direct payment of my fee must be registered prior to this assignment. I also understand that I can only
rescind this assignment prior to the date SSA notifies the claimant of the first favorable determination or decision. If I
previously assigned direct payment to another entity, this new assignment also constitutes a rescission of the prior
assignment.
Rescission of prior assignment - I, the representative whose name appears in Section 2 and whose signature appears
in Section 8, rescind my prior assignment of direct payment of my authorized fee.

Part D - Representative's Certifications
I accept this appointment and certify the following:
• I understand and agree that I will comply with all applicable SSA regulations, rules, and policies on the representation of parties,
including the Rules of conduct and standards of responsibility for representatives (20 CFR 404.1740-404.1799 and 416.1540416.1599).
• I will not charge, collect, or retain a fee for representational services that SSA has not approved or that is more than SSA
approved unless a regulatory exclusion applies.
• I understand that if I fail to comply with any SSA regulations, rules, or policies I may be suspended or disqualified from acting as
a representative before SSA.
• I will not disclose any information to any unauthorized party without the claimant's specific written consent.
• I am not currently suspended or disqualified from practicing before the SSA or another Federal agency.
• I will immediately disclose to SSA if I am suspended or disbarred by a Federal or State court, administrative tribunal, bar disciplinary
authority, or other authority during my appointment.
• I am not prohibited from representing the claimant as a current or former officer or employee of the United States.
• I accept appointment as the representative for the claimant named in Section 1 of this form in connection with the claims and
asserted rights described in Section 4 of this form.
• I agree that a copy of this signed form SSA-1696 will have the same force and effect as the original.
• I declare under penalty of perjury that I have examined all the information on this form and on all accompanying statements or
forms, including any information, attestations and certifications provided to SSA in registration, and that they are all currently
true and correct to the best of my knowledge.

I CERTIFY TO ALL OF THE ABOVE

(Representative's Initials)

Form SSA-1696 (XX-2026) UF

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Claimant's Social Security Number
_
_

Representative's Rep ID

Section 6 - Fee Arrangement (Representative Only)
Check one box below. If the representative is eligible for direct payment and this section is left unchecked, we will assume the
representative will seek direct payment of a fee unless we receive a written waiver.
I will request a fee and direct payment of this fee. Select this box if you are eligible for direct payment and want us to
withhold a portion of the past-due benefits to directly pay the fee we may authorize. (We must authorize the fee.)
I will request a fee but not direct payment. Select this box if you are not eligible for direct payment from the past-due
benefits, or if you do not want direct payment. You are responsible for collecting any fee we may authorize on your own.
(We must authorize the fee.)
I waive the right to receive a fee from the claimant, any auxiliary beneficiaries, or any other individual, but a thirdparty entity will pay my fee. Select this box to certify that an entity, or a Federal, state, county, or city government
agency will pay the fee and any expenses from its funds. The claimant, auxiliary beneficiaries, or other individuals must
not be liable for the fee, directly or indirectly, in whole or in part, or any expenses. (We do not need to authorize the fee if
all regulatory conditions apply.)
I waive the right to a fee.

Section 7 - Auxiliary Claimants
List any auxiliary claimants, such as a child or spouse of the claimant or number holder, who have not appointed their own
representative.

Social Security Number

First Name

Initial

Last Name

Section 8 - Signatures
Both you and your representative must sign this form if you are appointing a new representative. If you are updating information
about an existing appointment, see the Section 8 instructions for signature requirements.
Date
Representative's Signature
Claimant's Signature

Date