Appointment of Representative - SSA-1696 and e1696

Status: Original and derived artifacts are available for this document.

Download: pdf

Once user “Submit”

**Note for mock-up of changes: All instructions,
Paperwork Reduction Act, and Privacy Act statements
will be updated to match the revised SSA-1696. Edits
were not made in this version.
Edits to the screens begin on page 8. If the section is
repeated a second time in this screen package to show
the flow of screens for the user, the edits are not
repeated throughout the document.**

Instruction Language Change to:

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.

Zip Code
This information facilitates electronic work management system
routing of the electronic form, but is not necessary for the paper form.
We want to make sure it is kept in the SSA-1696-APP despite not
appearing on the SSA-1696.

Instruction Language Change to:

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.

Removed text box after Post-Entitlement Issue choice and
incorporated the "e.g." parenthetical content into the parenthetical

A new issue

following "Post-Entitlement Issue, which now reads: "

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"

Replace acknowledgment language with the following:

Suspended or disqualified from practice before SSA or any other
federal program or agency.
Convicted of a violation under Section 206 or 1631(d) of the Social
Security Act.
Disqualified from representing a claimant as a current or former
officer or employee of the United States.

Disbarred or suspended from a court or bar to which I was
previously admitted to practice as an attorney.
Removed or suspended by a professional licensing authority or
agency.

Part B instructions now read:
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".

We will add "or another Federal agency." to the "I am not currently
suspended or disqualified from practicing before the SSA"
certification and insert the following certification below it:
"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."

User selects the Initials box on the screen above:

Formatting (here and throughout):
Updated formatting of Name boxes throughout the form
for the sake of consistency.
Created submission forms for every SSN, Rep ID, and EIN
providing one box per digit, as this will help prevent
claimants and representatives from submitting obviously
incorrect numbers by accident.

Section 8 instructions now read: 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.

User selects the Representative’s Signature on screen above:

User selects the “Click to Sign” bottom right in the screen above:

The Password pop-up is displayed when user selects “download a copy” and upon opening the PDF:

The Password pop-up is displayed when user selects “Review and sign” from the email above:

User selected “Claimant’s Signature” in the screen above:

User selects the “Click to Sign” bottom right in the same screen above:

The Password pop-up is displayed when user selects “download a copy” and upon opening the PDF:

User selected the “Open Agreement” link in the email above.