SOCIAL SECURITY ADMINISTRATION
NON-ATTORNEY
REPRESENTATIVE DIRECT FEE PAYMENT DEMONSTRATION
PROJECT
ANNUAL
AFFIRMATIONS WORKSHEET
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In order to maintain demonstration project eligibility, you
must continue to meet all demonstration project
prerequisites, including passing a criminal background check
to ensure that you are fit to practice before the
Commissioner. To ensure that you continue to meet these
prerequisites, you must annually reaffirm your answers to the
following questions from your demonstration project
application:
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1. Have you been admitted 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 since the date you filed
your application to participate in the demonstration project?
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Yes
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No
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If Yes, please provide the following information:
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Name of Court:
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2. Have you been, by reason of misconduct, disbarred
or suspended from any court or bar to which you were
previously admitted to practice since the date you filed your
application to participate in the demonstration project?
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Yes
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No
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If Yes, please state whether you were disbarred, suspended,
or resigned in lieu of disciplinary proceedings:
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Details:
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3. Have you been, by reason of misconduct,
disqualified, sanctioned, or suspended from participating in
any Federal program or appearing before the Social Security
Administration or any other Federal Agency since the date you
filed your application to participate in the demonstration
project?
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Yes
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No
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If Yes, please provide the following information:
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Name of Program or Agency:
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Address of Program or Agency:
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Details of Disqualification, Sanction or Suspension:
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Date of disqualification, sanction, or suspension:
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Date of Reinstatement (if applicable):
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4. Are you currently being investigated by reason of
misconduct, by the Social Security Administration or any
other Federal agency for possible disqualification, sanction
or suspension?
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Yes
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No
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If Yes, please provide the following information:
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Name of Program or Agency:
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Address of Program or Agency:
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Details of Investigation:
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Date of Investigation:
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Status of Investigation:
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5. Have you had a judgment or lien assessed against
you by a civil court for malpractice and/or fraud since the
date you filed your application to participate in the
demonstration project?
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Yes
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No
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If Yes, explain the circumstances. You may submit additional
explanatory documents with your other application materials.
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Circumstances:
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6. Have you been determined to have fraudulently used
or misused any Social Security benefits since the date you
filed your application to participate in the demonstration
project?
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Yes
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No
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7. Have you been determined to have violated any
Social Security program rules (e.g. rules regarding the
disclosure of evidence or representative payee rules since
the date you filed your application to participate in the
demonstration project?
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Yes
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No
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8. Can you pass all aspects of the required criminal
background check, including a Social Security records check?
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Yes
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No
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9. Have you been convicted of a felony since the date
you filed your application to participate in the
demonstration project?
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Yes
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No
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Signature
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Date
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Privacy Act Statement
The information requested
on this worksheet is authorized by section 303 of the Social
Security Protection Act of 2004 (Public Law 108-203). The
information provided will be used to further document your
continued eligibility to participate in the demonstration
project authorized by section 303 and your eligibility to
receive direct payment of fees (from a claimant's past-due
benefits) for your representation services. Information
requested on this worksheet is voluntary. However, if you do
not provide the required information, a decision based on the
evidence in your file can result in a determination that you
are ineligible for direct payment of fees. While the
information you furnish on this worksheet would almost never
be used for any purpose other than making a determination
about your continued eligibility for direct payment of fees,
such information may be disclosed by the Social Security
Administration (SSA) for the following purposes (1) to assist
SSA in determining your eligibility for direct payment of
fees (2) to facilitate statistical research and audit
activities necessary to assure the integrity and improvement
of the demonstration project administered by SSA, and (3) to
comply with laws and regulations requiring the exchange of
information between SSA and another agency.
Please
initial indicating that you have read and understand the
Privacy Act Statement:
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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 10 minutes to read the
instructions, gather the facts, and answer the questions.
SEND THE COMPLETED WORKSHEET TO CPS HUMAN RESOURCE SERVICES.
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.
Please initial indicating that you have read and
understand the Paperwork Reduction Act Statement:
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