Social Security: ssa-1696
Content
Social Security Administration
Name (Claimant) (Print or Type) Wage Earner (If Different) Part I I appoint this person,
Please read the back of the last copy before you complete this form.
Social Security Number Social Security Number
Form Approved OMB No. 0960-0527
APPOINTMENT OF REPRESENTATIVE
(Name and Address)
,
to act as my representative in connection with my claim(s) or asserted right(s) under: Title II Title XVI Title XVIII Title VIII (RSDI) (SSI) (Medicare Coverage) (SVB) This person may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I appoint, or I now have, more than one representative. My main representative is .
(Name of Principal Representative)
Signature (Claimant) Telephone Number (with Area Code) Part II
Address Fax Number (with Area Code) Date
ACCEPTANCE OF APPOINTMENT
I, , hereby accept the above appointment. I certify that I have not been suspended or prohibited from practice before the Social Security Administration; that I am not disqualified from representing the claimant as a current or former officer or employee of the United States; and that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to on the reverse side of the representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will notify the Social Security Administration. (Completion of Part III satisfies this requirement.)
Check one:
I am an attorney.
I am a non-attorney who is eligible to receive direct fee payment.
I am not an attorney and I am ineligible to receive direct fee payment. I have been disbarred or suspended from a court or bar to which I was previously admitted to practice as an
attorney.
YES NO
I have been disqualified from participating in or appearing before a Federal program or agency.
YES
NO
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. Signature (Representative) Telephone Number (with Area Code) Address Fax Number (with Area Code) Date
Part III (Optional) WAIVER OF FEE I waive my right to charge and collect a fee under sections 206 and 1631(d)(2) of the Social Security Act. I release my client (the claimant) from any obligations, contractual or otherwise, which may be owed to me for services I have provided in connection with my client's claim(s) or asserted right(s). Signature (Representative) Date Part IV (Optional)
WAIVER OF DIRECT PAYMENT
by Attorney or Non-Attorney Eligible to Receive Direct Payment I waive only my right to direct payment of a fee from the withheld past-due retirement, survivors, disability insurance or supplemental security income benefits of my client (the claimant). I do not waive my right to request fee approval and to collect a fee directly from my client or a third party. Signature (Attorney or Eligible Non-Attorney (for Direct Payment) Representative) Date
Form SSA-1696-U4 (1-2005) EF (1-2005) Destroy Prior Editions (See Important Information on Reverse) FILE COPY
INFORMATION FOR CLAIMANTS
What a Representative May Do
We will work directly with your appointed representative unless he or she asks us to work directly with you. Your representative may: o o o o o et information from your claim(s) file; g give us evidence or information to support your claim; come with you, or for you, to any interview, conference, or hearing you have with us; request a reconsideration, hearing, or Appeals Council review; and elp you and your witnesses prepare for a hearing and h question any witnesses.
What Your Representative(s) May Charge, continued
o Filing A Fee Agreement If you and your representative have a written fee agreement, one of you must give it to us before we decide your claim(s). We usually will approve the agreement if you both signed it; the fee you agreed on is no more than 25 percent of past-due benefits, or $5,300 (or a higher amount we set and announced in the Federal Register), whichever is less; we approve your claim(s); and your claim results in past-due benefits. We will tell you in writing the amount of the fee your representative can charge based on the agreement. If we do not approve the fee agreement, we will tell you and your representative in writing. Then your representative must file a fee petition to charge and collect a fee. After we tell you the amount of the fee your representative can charge, you or your representative can ask us to look at it again if either or both of you disagree with the amount. (If we approved a fee agreement, the person who decided your claim(s) also may ask us to lower the amount.) Someone who did not decide the amount of the fee the first time will review and finally decide the amount of the fee.
Also, your representative will receive a copy of the decision(s) we make on your claim(s). We will rely on your representative to tell you about the status of your claim(s), but you still may call or visit us for information. You and your representative(s) are responsible for giving Social Security accurate information. It is wrong to willingly furnish false information. Doing so may result in criminal prosecution. We usually continue to work with your representative until (1) you tell us that he or she no longer represents you; or (2) your representative tells us that he or she is withdrawing or indicates that his or her services have ended (for example, by filing a fee petition or not pursuing an appeal). We do not continue to work with someone who is suspended or disqualified from representing claimants.
How Much You Pay
You never owe more than the fee we approve, except for: o o any fee a Federal court allows for your representative's
services before it; and
out-of-pocket expenses your representative incurs or expects to incur, for example, the cost of getting your
doctor's or hospital's records. Our approval is not
needed for such expenses.
What Your Representative(s) May Charge
Each representative you appoint can ask for a fee. To charge you a fee for services, your representative must get our approval. (Even when someone else will pay the fee for you, for example, an insurance company, your representative usually must get our approval.) One way is to file a fee petition. The other way is to file a fee agreement with us. In either case, your representative cannot charge you more than the fee amount we approve. If he or she does, promptly report this to your Social Security office. o Filing a Fee Petition Your representative may ask for approval of a fee by giving us a fee petition when his or her work on your claim(s) is complete. This written request describes in detail the amount of time he or she spent on each service provided you. The request also gives the amount of the fee the representative wants to charge for these services. Your representative must give you a copy of the fee petition and each attachment. If you disagree with the information shown in the fee petition, contact your Social Security office. Please do this within 20 days of receiving your copy of the petition. We will review the petition and consider the reasonable value of the services provided. Then we will tell you in writing the amount of the fee we approve.
Your representative may accept money in advance as long as he or she holds it in a trust or escrow account. If an attorney or a non-attorney who is eligible to receive direct fee payment represents you, and if your retirement, survivors, disability insurance, and/or supplemental security income claim(s) results in past-due benefits, we usually withhold 25 percent of your past-due benefits to pay toward the fee for you. You must pay your representative directly: o the rest of the fee you owe - if the amount of the fee is more than any amount(s) your representative held for you in a trust or escrow account and we withheld and paid your representative for you.
o all of the fee you owe - if we did not withhold past-due benefits, for example, because your representative waived direct payment, or you discharged the representative, or the representative withdrew from representing you before we issued a favorable decision; or if we withheld, but later paid you the money because your representative did not either ask for our approval until after 60 days of the date of your notice of award or tell us on time that he or she planned to ask for a fee.
Form SSA-1696-U4 (1-2005) EF (1-2005)
Social Security Administration
Name (Claimant) (Print or Type) Wage Earner (If Different) Part I I appoint this person,
Please read the back of the last copy before you complete this form.
Social Security Number Social Security Number
Form Approved OMB No. 0960-0527
APPOINTMENT OF REPRESENTATIVE
(Name and Address)
,
to act as my representative in connection with my claim(s) or asserted right(s) under: Title II Title XVI Title XVIII Title VIII (RSDI) (SSI) (Medicare Coverage) (SVB) This person may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I appoint, or I now have, more than one representative. My main representative is .
(Name of Principal Representative)
Signature (Claimant) Telephone Number (with Area Code) Part II
Address Fax Number (with Area Code) Date
ACCEPTANCE OF APPOINTMENT
I, , hereby accept the above appointment. I certify that I have not been suspended or prohibited from practice before the Social Security Administration; that I am not disqualified from representing the claimant as a current or former officer or employee of the United States; and that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to on the reverse side of the representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will notify the Social Security Administration. (Completion of Part III satisfies this requirement.)
Check one:
I am an attorney.
I am a non-attorney who is eligible to receive direct fee payment.
I am not an attorney and I am ineligible to receive direct fee payment. I have been disbarred or suspended from a court or bar to which I was previously admitted to practice as an
attorney.
YES NO
I have been disqualified from participating in or appearing before a Federal program or agency.
YES
NO
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. Signature (Representative) Telephone Number (with Area Code) Address Fax Number (with Area Code) Date
Part III (Optional) WAIVER OF FEE I waive my right to charge and collect a fee under sections 206 and 1631(d)(2) of the Social Security Act. I release my client (the claimant) from any obligations, contractual or otherwise, which may be owed to me for services I have provided in connection with my client's claim(s) or asserted right(s). Signature (Representative) Date Part IV (Optional)
WAIVER OF DIRECT PAYMENT
by Attorney or Non-Attorney Eligible to Receive Direct Payment I waive only my right to direct payment of a fee from the withheld past-due retirement, survivors, disability insurance or supplemental security income benefits of my client (the claimant). I do not waive my right to request fee approval and to collect a fee directly from my client or a third party. Signature (Attorney or Eligible Non-Attorney (for Direct Payment) Representative) Date
Form SSA-1696-U4 (1-2005) EF (1-2005) Destroy Prior Editions (See Important Information on Reverse) CLAIMANT'S COPY
INFORMATION FOR CLAIMANTS
What a Representative May Do
We will work directly with your appointed representative unless he or she asks us to work directly with you. Your representative may: o o o o o et information from your claim(s) file; g give us evidence or information to support your claim; come with you, or for you, to any interview, conference, or hearing you have with us; request a reconsideration, hearing, or Appeals Council review; and elp you and your witnesses prepare for a hearing and h question any witnesses.
What Your Representative(s) May Charge, continued
o Filing A Fee Agreement If you and your representative have a written fee agreement, one of you must give it to us before we decide your claim(s). We usually will approve the agreement if you both signed it; the fee you agreed on is no more than 25 percent of past-due benefits, or $5,300 (or a higher amount we set and announced in the Federal Register), whichever is less; we approve your claim(s); and your claim results in past-due benefits. We will tell you in writing the amount of the fee your representative can charge based on the agreement. If we do not approve the fee agreement, we will tell you and your representative in writing. Then your representative must file a fee petition to charge and collect a fee. After we tell you the amount of the fee your representative can charge, you or your representative can ask us to look at it again if either or both of you disagree with the amount. (If we approved a fee agreement, the person who decided your claim(s) also may ask us to lower the amount.) Someone who did not decide the amount of the fee the first time will review and finally decide the amount of the fee.
Also, your representative will receive a copy of the decision(s) we make on your claim(s). We will rely on your representative to tell you about the status of your claim(s), but you still may call or visit us for information. You and your representative(s) are responsible for giving Social Security accurate information. It is wrong to willingly furnish false information. Doing so may result in criminal prosecution. We usually continue to work with your representative until (1) you tell us that he or she no longer represents you; or (2) your representative tells us that he or she is withdrawing or indicates that his or her services have ended (for example, by filing a fee petition or not pursuing an appeal). We do not continue to work with someone who is suspended or disqualified from representing claimants.
How Much You Pay
You never owe more than the fee we approve, except for: o o any fee a Federal court allows for your representative's
services before it; and
out-of-pocket expenses your representative incurs or expects to incur, for example, the cost of getting your
doctor's or hospital's records. Our approval is not
needed for such expenses.
What Your Representative(s) May Charge
Each representative you appoint can ask for a fee. To charge you a fee for services, your representative must get our approval. (Even when someone else will pay the fee for you, for example, an insurance company, your representative usually must get our approval.) One way is to file a fee petition. The other way is to file a fee agreement with us. In either case, your representative cannot charge you more than the fee amount we approve. If he or she does, promptly report this to your Social Security office. o Filing a Fee Petition Your representative may ask for approval of a fee by giving us a fee petition when his or her work on your claim(s) is complete. This written request describes in detail the amount of time he or she spent on each service provided you. The request also gives the amount of the fee the representative wants to charge for these services. Your representative must give you a copy of the fee petition and each attachment. If you disagree with the information shown in the fee petition, contact your Social Security office. Please do this within 20 days of receiving your copy of the petition. We will review the petition and consider the reasonable value of the services provided. Then we will tell you in writing the amount of the fee we approve.
Your representative may accept money in advance as long as he or she holds it in a trust or escrow account. If an attorney or a non-attorney who is eligible to receive direct fee payment represents you, and if your retirement, survivors, disability insurance, and/or supplemental security income claim(s) results in past-due benefits, we usually withhold 25 percent of your past-due benefits to pay toward the fee for you. You must pay your representative directly: o the rest of the fee you owe - if the amount of the fee is more than any amount(s) your representative held for you in a trust or escrow account and we withheld and paid your representative for you.
o all of the fee you owe - if we did not withhold past-due benefits, for example, because your representative waived direct payment, or you discharged the representative, or the representative withdrew from representing you before we issued a favorable decision; or if we withheld, but later paid you the money because your representative did not either ask for our approval until after 60 days of the date of your notice of award or tell us on time that he or she planned to ask for a fee.
Form SSA-1696-U4 (1-2005) EF (1-2005)
Social Security Administration
Name (Claimant) (Print or Type) Wage Earner (If Different) Part I I appoint this person,
Please read the back of the last copy before you complete this form.
Social Security Number Social Security Number
Form Approved OMB No. 0960-0527
APPOINTMENT OF REPRESENTATIVE
(Name and Address)
,
to act as my representative in connection with my claim(s) or asserted right(s) under: Title II Title XVI Title XVIII Title VIII (RSDI) (SSI) (Medicare Coverage) (SVB) This person may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I appoint, or I now have, more than one representative. My main representative is .
(Name of Principal Representative)
Signature (Claimant) Telephone Number (with Area Code) Part II
Address Fax Number (with Area Code) Date
ACCEPTANCE OF APPOINTMENT
I, , hereby accept the above appointment. I certify that I have not been suspended or prohibited from practice before the Social Security Administration; that I am not disqualified from representing the claimant as a current or former officer or employee of the United States; and that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to on the reverse side of the representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will notify the Social Security Administration. (Completion of Part III satisfies this requirement.)
Check one:
I am an attorney.
I am a non-attorney who is eligible to receive direct fee payment.
I am not an attorney and I am ineligible to receive direct fee payment. I have been disbarred or suspended from a court or bar to which I was previously admitted to practice as an
attorney.
YES NO
I have been disqualified from participating in or appearing before a Federal program or agency.
YES
NO
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. Signature (Representative) Telephone Number (with Area Code) Address Fax Number (with Area Code) Date
Part III (Optional) WAIVER OF FEE I waive my right to charge and collect a fee under sections 206 and 1631(d)(2) of the Social Security Act. I release my client (the claimant) from any obligations, contractual or otherwise, which may be owed to me for services I have provided in connection with my client's claim(s) or asserted right(s). Signature (Representative) Date Part IV (Optional)
WAIVER OF DIRECT PAYMENT
by Attorney or Non-Attorney Eligible to Receive Direct Payment I waive only my right to direct payment of a fee from the withheld past-due retirement, survivors, disability insurance or supplemental security income benefits of my client (the claimant). I do not waive my right to request fee approval and to collect a fee directly from my client or a third party. Signature (Attorney or Eligible Non-Attorney (for Direct Payment) Representative) Date
Form SSA-1696-U4 (1-2005) EF (1-2005) Destroy Prior Editions (See Important Information on Reverse) REPRESENTATIVE COPY
INFORMATION FOR REPRESENTATIVES
Fees for Representation
An attorney or other person who wants to charge or collect a fee for providing services in connection with a claim before the Social Security Administration must first obtain our approval of the fee for representation. The only exceptions are if the fee is for services provided: o hen a nonprofit organization or government w agency will pay the fee and any expenses from government funds and the claimant incurs no liability, directly or indirectly, for the cost(s); o n an official capacity such as legal guardian, i committee, or similar court-appointed office and the court has approved the fee in question; or in representing the claimant before a court of law. A representative who has provided services in a claim before both the Social Security Administration and a court of law may seek a fee from either or both, but neither tribunal has the authority to set a fee for the other.
Collecting a Fee
You may accept money in advance, as long as you hold it in a trust or escrow account. The claimant never owes you more than the fee we approve, except for: o any fee a Federal court allows for your services before it; and o out-of-pocket expenses you incur or expect to incur, for example, the cost of getting evidence. Our approval is not needed for such expenses. If you are not an attorney and you are ineligible to receive direct payment, you must collect the approved fee from the claimant. If you are interested in becoming eligible to receive direct payment, you can find information on the procedures for becoming eligible for direct payment on our "Representing Claimants" website: http://www.ssa.gov/representation/. If you are an attorney or a non-attorney whom SSA has found eligible to receive direct payment, we usually withhold 25 percent of any past-due benefits that result from a favorably decided retirement, survivors, disability insurance, or supplemental security income claim. Once we approve a fee, we pay you all or part of the fee from the funds withheld. We will also charge you the assessment required by section 206(d) and 1631(d)(2)(C) of the Social Security Act. You cannot charge or collect this expense from the claimant. You must collect from the claimant: o the rest he or she owes - if the amount of the fee is more than the
amount of money we withheld and paid you for
the claimant, and any amount you held for
the claimant in a trust or escrow account.
o all of the fee he or she owes - if we did not withhold past-due benefits, for example, because there are no past-due benefits, or the claimant discharged you, or you withdrew from representing the claimant; or - if we withheld, but later paid the money to the claimant because you did not either ask for our approval until after 60 days of the date of the notice of award or tell us on time that you planned to ask for a fee.
o
Obtaining Approval of a Fee
To charge a fee for services, you must use one of two, mutually exclusive fee approval processes. You must file either a fee petition or a fee agreement with us. In either case, you cannot charge more than the fee amount we approve. o Fee Petition Process You may ask for approval of a fee by giving us a fee petition when you have completed your services to the claimant. This written request must describe in detail the amount of time you spent on each service provided and the amount of the fee you are requesting. You must give the claimant a copy of the fee petition and each attachment. The claimant may disagree with the information shown by contacting a Social Security office within 20 days of receiving his or her copy of the fee petition. We will consider the reasonable value of the services provided, and send you notice of the amount of the fee you can charge. o Fee Agreement Process If you and the claimant have a written fee agreement, either of you must give it to us before we decide the claim(s). We usually will approve the agreement if you both signed it; the fee you agreed on is no more than 25 percent of past-due benefits, or $5,300 (or a higher amount we set and announce in the Federal Register), whichever is less; we approve the claim(s); and the claim results in past-due benefits. We will send you a copy of the notice we send the claimant telling him or her the amount of the fee you can charge based on the agreement. If we do not approve the fee agreement, we will tell you in writing. We also will tell you and the claimant that you must file a fee petition if you wish to charge and collect a fee. After we tell you the amount of the fee you can charge, you or the claimant may ask us in writing to review the approved fee. (If we approved a fee agreement, the person who decided the claim(s) also may ask us to lower the amount.) Someone who did not decide the amount of the fee the first time will review and finally decide the amount of the fee. Form SSA-1696-U4 (1-2005) EF (1-2005)
Conflict of Interest and Penalties
For improper acts, you can be suspended or disqualified from representing anyone before the Social Security Administration. You also can face criminal prosecution. Improper acts include: o If you are or were an officer or employee of the United States, providing services as a representative in certain claims against and other matters affecting the Federal government. o Knowingly and willingly furnishing false information. o Charging or collecting an unauthorized fee or too much for services provided in any claim, including services before a court that made a favorable decision.
References
o 18 U.S.C. §§ 203, 205, and 207; and 42 U.S.C. §§ 406(a), 1320a-6, and 1383(d)(2) o 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq. o Social Security Rulings 88-10c, 85-3, 83-27, and 82-39
Social Security Administration
Name (Claimant) (Print or Type) Wage Earner (If Different) Part I I appoint this person,
Please read the back of the last copy before you complete this form.
Social Security Number Social Security Number
Form Approved OMB No. 0960-0527
APPOINTMENT OF REPRESENTATIVE
(Name and Address)
,
to act as my representative in connection with my claim(s) or asserted right(s) under: Title II Title XVI Title XVIII Title VIII (RSDI) (SSI) (Medicare Coverage) (SVB) This person may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I appoint, or I now have, more than one representative. My main representative is .
(Name of Principal Representative)
Signature (Claimant) Telephone Number (with Area Code) Part II
Address Fax Number (with Area Code) Date
ACCEPTANCE OF APPOINTMENT
I, , hereby accept the above appointment. I certify that I have not been suspended or prohibited from practice before the Social Security Administration; that I am not disqualified from representing the claimant as a current or former officer or employee of the United States; and that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to on the reverse side of the representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will notify the Social Security Administration. (Completion of Part III satisfies this requirement.)
Check one:
I am an attorney.
I am a non-attorney who is eligible to receive direct fee payment.
I am not an attorney and I am ineligible to receive direct fee payment. I have been disbarred or suspended from a court or bar to which I was previously admitted to practice as an
attorney.
YES NO
I have been disqualified from participating in or appearing before a Federal program or agency.
YES
NO
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. Signature (Representative) Telephone Number (with Area Code) Address Fax Number (with Area Code) Date
Part III (Optional) WAIVER OF FEE I waive my right to charge and collect a fee under sections 206 and 1631(d)(2) of the Social Security Act. I release my client (the claimant) from any obligations, contractual or otherwise, which may be owed to me for services I have provided in connection with my client's claim(s) or asserted right(s). Signature (Representative) Date Part IV (Optional)
WAIVER OF DIRECT PAYMENT
by Attorney or Non-Attorney Eligible to Receive Direct Payment I waive only my right to direct payment of a fee from the withheld past-due retirement, survivors, disability insurance or supplemental security income benefits of my client (the claimant). I do not waive my right to request fee approval and to collect a fee directly from my client or a third party. Signature (Attorney or Eligible Non-Attorney (for Direct Payment) Representative) Date
Form SSA-1696-U4 (1-2005) EF (1-2005) Destroy Prior Editions (See Important Information on Reverse) OHA COPY
COMPLETING THIS FORM TO APPOINT A REPRESENTATIVE
Choosing to Be Represented
You can choose to have a representative help you when you do business with Social Security. We will work with your representative, just as we would with you. It is important that you select a qualified person because, once appointed, your representative may act for you in most Social Security matters. We give more information, and examples of what a representative may do, on the back of the "Claimant's Copy" of this form.
How To Complete This Form, continued
Sign your name, but print or type your address, your area code and telephone number, and the date.
Part II Acceptance of Appointment
Each person you appoint (named in part I) completes this part, preferably in all cases. If the person is not an attorney, he or she must give his or her name, state that he or she accepts the appointment, and sign the form.
Paperwork and Privacy Act Notice
The Social Security Administration (SSA) will recognize someone else as your representative if you sign a written notice appointing that person and, if he or she is not an attorney, that person signs the notice agreeing to be your representative. (You can read more about this in our regulations: 20 CFR §§ 404.1707 and 416.1507.) Giving the information this form requests is voluntary. Without it though, we may not work with the person you choose to represent you.
Part III
(Optional)
Waiver of Fee
Your representative may complete this part if he or she will not charge any fee for the services provided in this claim. If you appoint a second representative or co-counsel who also will not charge a fee, he or she also should sign this part or give us a separate, written waiver statement.
How to Complete This Form
Please print or type. At the top, show your full name and your Social Security number. If your claim is based on another person's work and earnings, also show the ''wage earner's'' name and Social Security number. If you appoint more than one person, you may want to complete a form for each of them.
Part IV (Optional) Waiver of Direct Payment by an Attorney or a Non-Attorney Eligible to Receive Direct Payment
Your representative may complete this part if he or she is an attorney or a non-attorney who does not want direct payment of all or part of the approved fee from past-due retirement, survivors, disability insurance, or supplemental security income benefits withheld. Paperwork Reduction Act Statement - This information collection meets the 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 10 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
Part I Appointment of Representative
Give the name and address of the person(s) you are appointing. You may appoint an attorney or any other qualified person to represent you. You also may appoint more than one person, but see ''What Your Representative(s) May Charge'' on the back of the ''Claimant's Copy'' of this form. You can appoint one or more persons in a firm, corporation, or other organization as your representative(s), but you may not appoint a law firm, legal aid group, corporation, or organization itself. Check the block(s) showing the program(s) under which you have a claim. You may check more than one block. Check: o Title Il (RSDI), if your claim concerns retirement, survivors, or disability insurance benefits. T itle XVI (SSI), if your claim concerns supplemental security income. T itle XVIII (Medicare Coverage), if your claim concerns entitlement to Medicare or enrollment in the Supplementary Medical Insurance (SMI) plan.
References
o 18 U.S.C. §§ 203, 205, and 207; and 42 U.S.C. §§ 406(a), 1320a-6, and 1383(d)(2) 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq. Social Security Rulings 88-10c, 85-3, 83-27, and 82-39
o
o
o o
If you will have more than one representative, check the block and give the name of the person you want to be the main representative.
Form SSA-1696-U4 (1-2005) EF (1-2005)
Name (Claimant) (Print or Type) Wage Earner (If Different) Part I I appoint this person,
Please read the back of the last copy before you complete this form.
Social Security Number Social Security Number
Form Approved OMB No. 0960-0527
APPOINTMENT OF REPRESENTATIVE
(Name and Address)
,
to act as my representative in connection with my claim(s) or asserted right(s) under: Title II Title XVI Title XVIII Title VIII (RSDI) (SSI) (Medicare Coverage) (SVB) This person may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I appoint, or I now have, more than one representative. My main representative is .
(Name of Principal Representative)
Signature (Claimant) Telephone Number (with Area Code) Part II
Address Fax Number (with Area Code) Date
ACCEPTANCE OF APPOINTMENT
I, , hereby accept the above appointment. I certify that I have not been suspended or prohibited from practice before the Social Security Administration; that I am not disqualified from representing the claimant as a current or former officer or employee of the United States; and that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to on the reverse side of the representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will notify the Social Security Administration. (Completion of Part III satisfies this requirement.)
Check one:
I am an attorney.
I am a non-attorney who is eligible to receive direct fee payment.
I am not an attorney and I am ineligible to receive direct fee payment. I have been disbarred or suspended from a court or bar to which I was previously admitted to practice as an
attorney.
YES NO
I have been disqualified from participating in or appearing before a Federal program or agency.
YES
NO
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. Signature (Representative) Telephone Number (with Area Code) Address Fax Number (with Area Code) Date
Part III (Optional) WAIVER OF FEE I waive my right to charge and collect a fee under sections 206 and 1631(d)(2) of the Social Security Act. I release my client (the claimant) from any obligations, contractual or otherwise, which may be owed to me for services I have provided in connection with my client's claim(s) or asserted right(s). Signature (Representative) Date Part IV (Optional)
WAIVER OF DIRECT PAYMENT
by Attorney or Non-Attorney Eligible to Receive Direct Payment I waive only my right to direct payment of a fee from the withheld past-due retirement, survivors, disability insurance or supplemental security income benefits of my client (the claimant). I do not waive my right to request fee approval and to collect a fee directly from my client or a third party. Signature (Attorney or Eligible Non-Attorney (for Direct Payment) Representative) Date
Form SSA-1696-U4 (1-2005) EF (1-2005) Destroy Prior Editions (See Important Information on Reverse) FILE COPY
INFORMATION FOR CLAIMANTS
What a Representative May Do
We will work directly with your appointed representative unless he or she asks us to work directly with you. Your representative may: o o o o o et information from your claim(s) file; g give us evidence or information to support your claim; come with you, or for you, to any interview, conference, or hearing you have with us; request a reconsideration, hearing, or Appeals Council review; and elp you and your witnesses prepare for a hearing and h question any witnesses.
What Your Representative(s) May Charge, continued
o Filing A Fee Agreement If you and your representative have a written fee agreement, one of you must give it to us before we decide your claim(s). We usually will approve the agreement if you both signed it; the fee you agreed on is no more than 25 percent of past-due benefits, or $5,300 (or a higher amount we set and announced in the Federal Register), whichever is less; we approve your claim(s); and your claim results in past-due benefits. We will tell you in writing the amount of the fee your representative can charge based on the agreement. If we do not approve the fee agreement, we will tell you and your representative in writing. Then your representative must file a fee petition to charge and collect a fee. After we tell you the amount of the fee your representative can charge, you or your representative can ask us to look at it again if either or both of you disagree with the amount. (If we approved a fee agreement, the person who decided your claim(s) also may ask us to lower the amount.) Someone who did not decide the amount of the fee the first time will review and finally decide the amount of the fee.
Also, your representative will receive a copy of the decision(s) we make on your claim(s). We will rely on your representative to tell you about the status of your claim(s), but you still may call or visit us for information. You and your representative(s) are responsible for giving Social Security accurate information. It is wrong to willingly furnish false information. Doing so may result in criminal prosecution. We usually continue to work with your representative until (1) you tell us that he or she no longer represents you; or (2) your representative tells us that he or she is withdrawing or indicates that his or her services have ended (for example, by filing a fee petition or not pursuing an appeal). We do not continue to work with someone who is suspended or disqualified from representing claimants.
How Much You Pay
You never owe more than the fee we approve, except for: o o any fee a Federal court allows for your representative's
services before it; and
out-of-pocket expenses your representative incurs or expects to incur, for example, the cost of getting your
doctor's or hospital's records. Our approval is not
needed for such expenses.
What Your Representative(s) May Charge
Each representative you appoint can ask for a fee. To charge you a fee for services, your representative must get our approval. (Even when someone else will pay the fee for you, for example, an insurance company, your representative usually must get our approval.) One way is to file a fee petition. The other way is to file a fee agreement with us. In either case, your representative cannot charge you more than the fee amount we approve. If he or she does, promptly report this to your Social Security office. o Filing a Fee Petition Your representative may ask for approval of a fee by giving us a fee petition when his or her work on your claim(s) is complete. This written request describes in detail the amount of time he or she spent on each service provided you. The request also gives the amount of the fee the representative wants to charge for these services. Your representative must give you a copy of the fee petition and each attachment. If you disagree with the information shown in the fee petition, contact your Social Security office. Please do this within 20 days of receiving your copy of the petition. We will review the petition and consider the reasonable value of the services provided. Then we will tell you in writing the amount of the fee we approve.
Your representative may accept money in advance as long as he or she holds it in a trust or escrow account. If an attorney or a non-attorney who is eligible to receive direct fee payment represents you, and if your retirement, survivors, disability insurance, and/or supplemental security income claim(s) results in past-due benefits, we usually withhold 25 percent of your past-due benefits to pay toward the fee for you. You must pay your representative directly: o the rest of the fee you owe - if the amount of the fee is more than any amount(s) your representative held for you in a trust or escrow account and we withheld and paid your representative for you.
o all of the fee you owe - if we did not withhold past-due benefits, for example, because your representative waived direct payment, or you discharged the representative, or the representative withdrew from representing you before we issued a favorable decision; or if we withheld, but later paid you the money because your representative did not either ask for our approval until after 60 days of the date of your notice of award or tell us on time that he or she planned to ask for a fee.
Form SSA-1696-U4 (1-2005) EF (1-2005)
Social Security Administration
Name (Claimant) (Print or Type) Wage Earner (If Different) Part I I appoint this person,
Please read the back of the last copy before you complete this form.
Social Security Number Social Security Number
Form Approved OMB No. 0960-0527
APPOINTMENT OF REPRESENTATIVE
(Name and Address)
,
to act as my representative in connection with my claim(s) or asserted right(s) under: Title II Title XVI Title XVIII Title VIII (RSDI) (SSI) (Medicare Coverage) (SVB) This person may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I appoint, or I now have, more than one representative. My main representative is .
(Name of Principal Representative)
Signature (Claimant) Telephone Number (with Area Code) Part II
Address Fax Number (with Area Code) Date
ACCEPTANCE OF APPOINTMENT
I, , hereby accept the above appointment. I certify that I have not been suspended or prohibited from practice before the Social Security Administration; that I am not disqualified from representing the claimant as a current or former officer or employee of the United States; and that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to on the reverse side of the representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will notify the Social Security Administration. (Completion of Part III satisfies this requirement.)
Check one:
I am an attorney.
I am a non-attorney who is eligible to receive direct fee payment.
I am not an attorney and I am ineligible to receive direct fee payment. I have been disbarred or suspended from a court or bar to which I was previously admitted to practice as an
attorney.
YES NO
I have been disqualified from participating in or appearing before a Federal program or agency.
YES
NO
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. Signature (Representative) Telephone Number (with Area Code) Address Fax Number (with Area Code) Date
Part III (Optional) WAIVER OF FEE I waive my right to charge and collect a fee under sections 206 and 1631(d)(2) of the Social Security Act. I release my client (the claimant) from any obligations, contractual or otherwise, which may be owed to me for services I have provided in connection with my client's claim(s) or asserted right(s). Signature (Representative) Date Part IV (Optional)
WAIVER OF DIRECT PAYMENT
by Attorney or Non-Attorney Eligible to Receive Direct Payment I waive only my right to direct payment of a fee from the withheld past-due retirement, survivors, disability insurance or supplemental security income benefits of my client (the claimant). I do not waive my right to request fee approval and to collect a fee directly from my client or a third party. Signature (Attorney or Eligible Non-Attorney (for Direct Payment) Representative) Date
Form SSA-1696-U4 (1-2005) EF (1-2005) Destroy Prior Editions (See Important Information on Reverse) CLAIMANT'S COPY
INFORMATION FOR CLAIMANTS
What a Representative May Do
We will work directly with your appointed representative unless he or she asks us to work directly with you. Your representative may: o o o o o et information from your claim(s) file; g give us evidence or information to support your claim; come with you, or for you, to any interview, conference, or hearing you have with us; request a reconsideration, hearing, or Appeals Council review; and elp you and your witnesses prepare for a hearing and h question any witnesses.
What Your Representative(s) May Charge, continued
o Filing A Fee Agreement If you and your representative have a written fee agreement, one of you must give it to us before we decide your claim(s). We usually will approve the agreement if you both signed it; the fee you agreed on is no more than 25 percent of past-due benefits, or $5,300 (or a higher amount we set and announced in the Federal Register), whichever is less; we approve your claim(s); and your claim results in past-due benefits. We will tell you in writing the amount of the fee your representative can charge based on the agreement. If we do not approve the fee agreement, we will tell you and your representative in writing. Then your representative must file a fee petition to charge and collect a fee. After we tell you the amount of the fee your representative can charge, you or your representative can ask us to look at it again if either or both of you disagree with the amount. (If we approved a fee agreement, the person who decided your claim(s) also may ask us to lower the amount.) Someone who did not decide the amount of the fee the first time will review and finally decide the amount of the fee.
Also, your representative will receive a copy of the decision(s) we make on your claim(s). We will rely on your representative to tell you about the status of your claim(s), but you still may call or visit us for information. You and your representative(s) are responsible for giving Social Security accurate information. It is wrong to willingly furnish false information. Doing so may result in criminal prosecution. We usually continue to work with your representative until (1) you tell us that he or she no longer represents you; or (2) your representative tells us that he or she is withdrawing or indicates that his or her services have ended (for example, by filing a fee petition or not pursuing an appeal). We do not continue to work with someone who is suspended or disqualified from representing claimants.
How Much You Pay
You never owe more than the fee we approve, except for: o o any fee a Federal court allows for your representative's
services before it; and
out-of-pocket expenses your representative incurs or expects to incur, for example, the cost of getting your
doctor's or hospital's records. Our approval is not
needed for such expenses.
What Your Representative(s) May Charge
Each representative you appoint can ask for a fee. To charge you a fee for services, your representative must get our approval. (Even when someone else will pay the fee for you, for example, an insurance company, your representative usually must get our approval.) One way is to file a fee petition. The other way is to file a fee agreement with us. In either case, your representative cannot charge you more than the fee amount we approve. If he or she does, promptly report this to your Social Security office. o Filing a Fee Petition Your representative may ask for approval of a fee by giving us a fee petition when his or her work on your claim(s) is complete. This written request describes in detail the amount of time he or she spent on each service provided you. The request also gives the amount of the fee the representative wants to charge for these services. Your representative must give you a copy of the fee petition and each attachment. If you disagree with the information shown in the fee petition, contact your Social Security office. Please do this within 20 days of receiving your copy of the petition. We will review the petition and consider the reasonable value of the services provided. Then we will tell you in writing the amount of the fee we approve.
Your representative may accept money in advance as long as he or she holds it in a trust or escrow account. If an attorney or a non-attorney who is eligible to receive direct fee payment represents you, and if your retirement, survivors, disability insurance, and/or supplemental security income claim(s) results in past-due benefits, we usually withhold 25 percent of your past-due benefits to pay toward the fee for you. You must pay your representative directly: o the rest of the fee you owe - if the amount of the fee is more than any amount(s) your representative held for you in a trust or escrow account and we withheld and paid your representative for you.
o all of the fee you owe - if we did not withhold past-due benefits, for example, because your representative waived direct payment, or you discharged the representative, or the representative withdrew from representing you before we issued a favorable decision; or if we withheld, but later paid you the money because your representative did not either ask for our approval until after 60 days of the date of your notice of award or tell us on time that he or she planned to ask for a fee.
Form SSA-1696-U4 (1-2005) EF (1-2005)
Social Security Administration
Name (Claimant) (Print or Type) Wage Earner (If Different) Part I I appoint this person,
Please read the back of the last copy before you complete this form.
Social Security Number Social Security Number
Form Approved OMB No. 0960-0527
APPOINTMENT OF REPRESENTATIVE
(Name and Address)
,
to act as my representative in connection with my claim(s) or asserted right(s) under: Title II Title XVI Title XVIII Title VIII (RSDI) (SSI) (Medicare Coverage) (SVB) This person may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I appoint, or I now have, more than one representative. My main representative is .
(Name of Principal Representative)
Signature (Claimant) Telephone Number (with Area Code) Part II
Address Fax Number (with Area Code) Date
ACCEPTANCE OF APPOINTMENT
I, , hereby accept the above appointment. I certify that I have not been suspended or prohibited from practice before the Social Security Administration; that I am not disqualified from representing the claimant as a current or former officer or employee of the United States; and that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to on the reverse side of the representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will notify the Social Security Administration. (Completion of Part III satisfies this requirement.)
Check one:
I am an attorney.
I am a non-attorney who is eligible to receive direct fee payment.
I am not an attorney and I am ineligible to receive direct fee payment. I have been disbarred or suspended from a court or bar to which I was previously admitted to practice as an
attorney.
YES NO
I have been disqualified from participating in or appearing before a Federal program or agency.
YES
NO
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. Signature (Representative) Telephone Number (with Area Code) Address Fax Number (with Area Code) Date
Part III (Optional) WAIVER OF FEE I waive my right to charge and collect a fee under sections 206 and 1631(d)(2) of the Social Security Act. I release my client (the claimant) from any obligations, contractual or otherwise, which may be owed to me for services I have provided in connection with my client's claim(s) or asserted right(s). Signature (Representative) Date Part IV (Optional)
WAIVER OF DIRECT PAYMENT
by Attorney or Non-Attorney Eligible to Receive Direct Payment I waive only my right to direct payment of a fee from the withheld past-due retirement, survivors, disability insurance or supplemental security income benefits of my client (the claimant). I do not waive my right to request fee approval and to collect a fee directly from my client or a third party. Signature (Attorney or Eligible Non-Attorney (for Direct Payment) Representative) Date
Form SSA-1696-U4 (1-2005) EF (1-2005) Destroy Prior Editions (See Important Information on Reverse) REPRESENTATIVE COPY
INFORMATION FOR REPRESENTATIVES
Fees for Representation
An attorney or other person who wants to charge or collect a fee for providing services in connection with a claim before the Social Security Administration must first obtain our approval of the fee for representation. The only exceptions are if the fee is for services provided: o hen a nonprofit organization or government w agency will pay the fee and any expenses from government funds and the claimant incurs no liability, directly or indirectly, for the cost(s); o n an official capacity such as legal guardian, i committee, or similar court-appointed office and the court has approved the fee in question; or in representing the claimant before a court of law. A representative who has provided services in a claim before both the Social Security Administration and a court of law may seek a fee from either or both, but neither tribunal has the authority to set a fee for the other.
Collecting a Fee
You may accept money in advance, as long as you hold it in a trust or escrow account. The claimant never owes you more than the fee we approve, except for: o any fee a Federal court allows for your services before it; and o out-of-pocket expenses you incur or expect to incur, for example, the cost of getting evidence. Our approval is not needed for such expenses. If you are not an attorney and you are ineligible to receive direct payment, you must collect the approved fee from the claimant. If you are interested in becoming eligible to receive direct payment, you can find information on the procedures for becoming eligible for direct payment on our "Representing Claimants" website: http://www.ssa.gov/representation/. If you are an attorney or a non-attorney whom SSA has found eligible to receive direct payment, we usually withhold 25 percent of any past-due benefits that result from a favorably decided retirement, survivors, disability insurance, or supplemental security income claim. Once we approve a fee, we pay you all or part of the fee from the funds withheld. We will also charge you the assessment required by section 206(d) and 1631(d)(2)(C) of the Social Security Act. You cannot charge or collect this expense from the claimant. You must collect from the claimant: o the rest he or she owes - if the amount of the fee is more than the
amount of money we withheld and paid you for
the claimant, and any amount you held for
the claimant in a trust or escrow account.
o all of the fee he or she owes - if we did not withhold past-due benefits, for example, because there are no past-due benefits, or the claimant discharged you, or you withdrew from representing the claimant; or - if we withheld, but later paid the money to the claimant because you did not either ask for our approval until after 60 days of the date of the notice of award or tell us on time that you planned to ask for a fee.
o
Obtaining Approval of a Fee
To charge a fee for services, you must use one of two, mutually exclusive fee approval processes. You must file either a fee petition or a fee agreement with us. In either case, you cannot charge more than the fee amount we approve. o Fee Petition Process You may ask for approval of a fee by giving us a fee petition when you have completed your services to the claimant. This written request must describe in detail the amount of time you spent on each service provided and the amount of the fee you are requesting. You must give the claimant a copy of the fee petition and each attachment. The claimant may disagree with the information shown by contacting a Social Security office within 20 days of receiving his or her copy of the fee petition. We will consider the reasonable value of the services provided, and send you notice of the amount of the fee you can charge. o Fee Agreement Process If you and the claimant have a written fee agreement, either of you must give it to us before we decide the claim(s). We usually will approve the agreement if you both signed it; the fee you agreed on is no more than 25 percent of past-due benefits, or $5,300 (or a higher amount we set and announce in the Federal Register), whichever is less; we approve the claim(s); and the claim results in past-due benefits. We will send you a copy of the notice we send the claimant telling him or her the amount of the fee you can charge based on the agreement. If we do not approve the fee agreement, we will tell you in writing. We also will tell you and the claimant that you must file a fee petition if you wish to charge and collect a fee. After we tell you the amount of the fee you can charge, you or the claimant may ask us in writing to review the approved fee. (If we approved a fee agreement, the person who decided the claim(s) also may ask us to lower the amount.) Someone who did not decide the amount of the fee the first time will review and finally decide the amount of the fee. Form SSA-1696-U4 (1-2005) EF (1-2005)
Conflict of Interest and Penalties
For improper acts, you can be suspended or disqualified from representing anyone before the Social Security Administration. You also can face criminal prosecution. Improper acts include: o If you are or were an officer or employee of the United States, providing services as a representative in certain claims against and other matters affecting the Federal government. o Knowingly and willingly furnishing false information. o Charging or collecting an unauthorized fee or too much for services provided in any claim, including services before a court that made a favorable decision.
References
o 18 U.S.C. §§ 203, 205, and 207; and 42 U.S.C. §§ 406(a), 1320a-6, and 1383(d)(2) o 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq. o Social Security Rulings 88-10c, 85-3, 83-27, and 82-39
Social Security Administration
Name (Claimant) (Print or Type) Wage Earner (If Different) Part I I appoint this person,
Please read the back of the last copy before you complete this form.
Social Security Number Social Security Number
Form Approved OMB No. 0960-0527
APPOINTMENT OF REPRESENTATIVE
(Name and Address)
,
to act as my representative in connection with my claim(s) or asserted right(s) under: Title II Title XVI Title XVIII Title VIII (RSDI) (SSI) (Medicare Coverage) (SVB) This person may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I appoint, or I now have, more than one representative. My main representative is .
(Name of Principal Representative)
Signature (Claimant) Telephone Number (with Area Code) Part II
Address Fax Number (with Area Code) Date
ACCEPTANCE OF APPOINTMENT
I, , hereby accept the above appointment. I certify that I have not been suspended or prohibited from practice before the Social Security Administration; that I am not disqualified from representing the claimant as a current or former officer or employee of the United States; and that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to on the reverse side of the representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will notify the Social Security Administration. (Completion of Part III satisfies this requirement.)
Check one:
I am an attorney.
I am a non-attorney who is eligible to receive direct fee payment.
I am not an attorney and I am ineligible to receive direct fee payment. I have been disbarred or suspended from a court or bar to which I was previously admitted to practice as an
attorney.
YES NO
I have been disqualified from participating in or appearing before a Federal program or agency.
YES
NO
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. Signature (Representative) Telephone Number (with Area Code) Address Fax Number (with Area Code) Date
Part III (Optional) WAIVER OF FEE I waive my right to charge and collect a fee under sections 206 and 1631(d)(2) of the Social Security Act. I release my client (the claimant) from any obligations, contractual or otherwise, which may be owed to me for services I have provided in connection with my client's claim(s) or asserted right(s). Signature (Representative) Date Part IV (Optional)
WAIVER OF DIRECT PAYMENT
by Attorney or Non-Attorney Eligible to Receive Direct Payment I waive only my right to direct payment of a fee from the withheld past-due retirement, survivors, disability insurance or supplemental security income benefits of my client (the claimant). I do not waive my right to request fee approval and to collect a fee directly from my client or a third party. Signature (Attorney or Eligible Non-Attorney (for Direct Payment) Representative) Date
Form SSA-1696-U4 (1-2005) EF (1-2005) Destroy Prior Editions (See Important Information on Reverse) OHA COPY
COMPLETING THIS FORM TO APPOINT A REPRESENTATIVE
Choosing to Be Represented
You can choose to have a representative help you when you do business with Social Security. We will work with your representative, just as we would with you. It is important that you select a qualified person because, once appointed, your representative may act for you in most Social Security matters. We give more information, and examples of what a representative may do, on the back of the "Claimant's Copy" of this form.
How To Complete This Form, continued
Sign your name, but print or type your address, your area code and telephone number, and the date.
Part II Acceptance of Appointment
Each person you appoint (named in part I) completes this part, preferably in all cases. If the person is not an attorney, he or she must give his or her name, state that he or she accepts the appointment, and sign the form.
Paperwork and Privacy Act Notice
The Social Security Administration (SSA) will recognize someone else as your representative if you sign a written notice appointing that person and, if he or she is not an attorney, that person signs the notice agreeing to be your representative. (You can read more about this in our regulations: 20 CFR §§ 404.1707 and 416.1507.) Giving the information this form requests is voluntary. Without it though, we may not work with the person you choose to represent you.
Part III
(Optional)
Waiver of Fee
Your representative may complete this part if he or she will not charge any fee for the services provided in this claim. If you appoint a second representative or co-counsel who also will not charge a fee, he or she also should sign this part or give us a separate, written waiver statement.
How to Complete This Form
Please print or type. At the top, show your full name and your Social Security number. If your claim is based on another person's work and earnings, also show the ''wage earner's'' name and Social Security number. If you appoint more than one person, you may want to complete a form for each of them.
Part IV (Optional) Waiver of Direct Payment by an Attorney or a Non-Attorney Eligible to Receive Direct Payment
Your representative may complete this part if he or she is an attorney or a non-attorney who does not want direct payment of all or part of the approved fee from past-due retirement, survivors, disability insurance, or supplemental security income benefits withheld. Paperwork Reduction Act Statement - This information collection meets the 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 10 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
Part I Appointment of Representative
Give the name and address of the person(s) you are appointing. You may appoint an attorney or any other qualified person to represent you. You also may appoint more than one person, but see ''What Your Representative(s) May Charge'' on the back of the ''Claimant's Copy'' of this form. You can appoint one or more persons in a firm, corporation, or other organization as your representative(s), but you may not appoint a law firm, legal aid group, corporation, or organization itself. Check the block(s) showing the program(s) under which you have a claim. You may check more than one block. Check: o Title Il (RSDI), if your claim concerns retirement, survivors, or disability insurance benefits. T itle XVI (SSI), if your claim concerns supplemental security income. T itle XVIII (Medicare Coverage), if your claim concerns entitlement to Medicare or enrollment in the Supplementary Medical Insurance (SMI) plan.
References
o 18 U.S.C. §§ 203, 205, and 207; and 42 U.S.C. §§ 406(a), 1320a-6, and 1383(d)(2) 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq. Social Security Rulings 88-10c, 85-3, 83-27, and 82-39
o
o
o o
If you will have more than one representative, check the block and give the name of the person you want to be the main representative.
Form SSA-1696-U4 (1-2005) EF (1-2005)
