Document
Claimant's Revocation of the Appointment of a Representative - SSA-1696-SUP1
ICR 202606-0960-009 · OMB 0960-0527 · Object 171427800.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Claimant's Revocation of the Appointment of a Representative - SSA-1696-SUP1 |
| Author | Sasha Nsafoah |
| Last Modified By | Writer |
| File Modified | 2026-07-31 |
| File Created | 2026-08-01 |
| Conversion State | complete |
Extracted Text
SSA will insert the following revised Privacy Act Statement into the form as soon as possible: 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 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.