Information Collection

Claimants - SSA-1696 and e1696

IC 281175 under ICR 202606-0960-009 · OMB 0960-0527.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1696 Appointment of Representative Claimants - SSA-1696 and e1696	Form and Instruction
Form SSA-1696 Appointment of Representative Claimants - SSA-1696 and e1696	Form and Instruction
Form SSA-1696 Appointment of Representative Claimants - SSA-1696 and e1696	Form and Instruction
Form SSA-1696 Appointment of Representative Claimants - SSA-1696 and e1696	Form and Instruction
SSA-1696-APP -e1696- Screens - Revised Version.pdf secure.ssa.gov/ssa1696/front-end/	Other-Internet Screens
SSA-1696-APP -e1696- Screens - Revised Version.pdf secure.ssa.gov/ssa1696/front-end/	Other-Internet Screens
SSA-1696 - Revised PA Statement.docx	Other-Revised Privacy Act Statement
SSA-1696 - Revised PA Statement.docx	Other-Revised Privacy Act Statement
SSA-1696 Appointment of Representative SSA-1696 - Revised Version (marked up).pdf	Form and Instruction
SSA-1696 Appointment of Representative SSA-1696 - Revised Version (marked up).pdf	Form and Instruction
SSA-1696 Appointment of Representative SSA-1696 - Revised Version (mock-up).pdf	Form and Instruction
SSA-1696 Appointment of Representative SSA-1696 - Revised Version (mock-up).pdf	Form and Instruction
SSA-1696-BK - Current Version.pdf Current SSA-1696-BK	IC Document
SSA-1696-BK - Current Version.pdf Current SSA-1696-BK	IC Document
SSA-1696-APP Screens - Current Version.pdf Current SSA-1696-APP (e1696)	IC Document
SSA-1696-APP Screens - Current Version.pdf Current SSA-1696-APP (e1696)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.1707 20 CFR 404.1720 20 CFR 408.1101 20 CFR 416.1507 20 CFR 416.1520

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-1696	www.ssa.gov (Upload Documents)	No		Paper Only
Form and Instruction	SSA-1696	www.ssa.gov (Upload Documents)	Yes	Yes	Fillable Printable
Other-Internet Screens		https://secure.ssa.gov/ssa1696/front-end/	Yes	Yes	Fillable Fileable Signable
Other-Revised Privacy Act Statement		www.ssa.gov	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,852,171

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,852,171	1,852,171
Annual IC Time Burden (Hours)	308,695	308,695
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-1696-BK		07/30/2026
Current SSA-1696-APP (e1696)		07/30/2026

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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