Non-Attorney Repersentative Demonstration Project -- Pap

Social Security Administration Non-Attorney Representative Demonstration Project

OMB No. 0960-0699

You must complete this application carefully and provide all supporting documentation. You must provide all required information before the end of the application period to be eligible for the Demonstration Project. If you have any questions, please call CPS Human Resource Services toll free at 1-800-376-5728 or see the “What's New?” page of their website at http://www.cps.ca.gov/tlc/ssa/new.asp for tips to make the application process easier.

Purpose of this Form
Section 303 of the Social Security Protection Act of 2004 (SSPA) Public Law no.108-203 provides for a 5-year demonstration project to be conducted by SSA under which the direct payment of SSA-approved fees is extended to certain non-attorney claimant representatives. Under the SSPA, to be eligible for direct payment of fees, a non-attorney representative must fulfill the following statutory requirements: (1) Possess a bachelors degree or have equivalent qualifications derived from training and work experience; (2) pass an examination that tests knowledge of the relevant provisions of the Social Security Act; (3) secure professional liability insurance or equivalent insurance; (4) pass a background check; and (5) demonstrate completion of relevant continuing education courses.

Section 303(b) of the SSPA permits the Commissioner of Social Security to establish additional prerequisites. Pursuant to that authority, the Commissioner will require applicants to satisfy a representational experience requirement to participate in the demonstration project.

Through the services of a private contractor, CPS Human Resource Services, SSA must collect the requested information to determine if a non-attorney representative has met the requirements to be eligible for direct payment of fees for his or her claimant representation services. The information collection is needed to comply with the legislation. The respondents are non-attorney representatives who apply for direct payment of fees.

Application Fee
SSPA section 303(c) (1) provides that the Commissioner may assess applicants a reasonable fee to cover the costs of administering the prerequisites process. The fee will be $1000 (in U.S. dollars) per applicant;

Applicants must include the fee payment with their application package;

Acceptable forms of fee payment will be by certified check, money order, a check drawn from a private firm's account, or credit card;

Applicants will pay their fees to CPS Human Resource Services; and

Applicants who are not found to be eligible may reapply during the next application phase, but they will pay the full fee upon reapplying.

Education and Equivalent Qualifications
A bachelor's degree from an accredited institution of higher education has been established as a prerequisite for participating in the demonstration project. However, applicants who do not have a bachelor's degree may satisfy this prerequisite based on combinations of training and work experience that the Commissioner determines to be equivalent to a bachelor's degree. We have determined that any of the following combinations of education and experience shall be equivalent to having a bachelor's degree:

• If the applicant does not have a bachelor's degree, but has three years or more of undergraduate study at an accredited institution of higher learning, the applicant must have at least one year of relevant professional experience (as defined below), at least six months of which must have involved claims for benefits under title II or title XVI of the Act;

• If the applicant has at least two, but less than three years of undergraduate study at an accredited institution of higher learning, the applicant must have at least two years of relevant professional experience, at least one year of which must have involved claims for benefits under title II or title XVI of the Act;

• If the applicant has at least one, but less than two years of undergraduate study at an accredited institution of higher learning, the applicant must have at least three years of relevant professional experience, at least two years of which must have involved claims for benefits under title II or XVI of the Act; or

• If the applicant has less than one year of undergraduate study at an accredited institution of higher learning, or no undergraduate education, the applicant must have received a high school diploma or GED certificate and have at least four years of relevant professional experience, at least two years of which must have involved claims for benefits under title II or title XVI of the Act.

Relevant professional experience (for purposes of establishing qualifications equivalent to a bachelor's degree) is work through which the applicant has demonstrated familiarity with medical reports and an ability to describe and assess mental and/or physical limitations. Such experience may be from the fields of: Teaching, counseling or guidance, social work, personnel management, public employment service, and/or nursing or other health care professional services. Any professional work involving claims for benefits under title II or title XVI of the Act shall also be defined as relevant professional experience.

An applicant who fails to submit proof of a bachelor's degree or equivalent qualifications before the application period closes shall be precluded from establishing, based on his or her current application, eligibility to take the examination and to participate in the demonstration project. However, the applicant may re-apply to participate in the demonstration project during a subsequent application period. Proof of Education is an official transcript showing the stamp or raised seal, or otherwise establishing that it is an official copy.

An applicant may possess a law degree (e.g., juris doctor); however, attorneys who already qualify to have their approved representatives' fees paid directly from their clients' past-due benefits pursuant to sections 206 and 1631(d)(2) of the Act will be ineligible to participate in this demonstration project. In addition, attorneys who are suspended or disbarred by a State or Federal court or disqualified from appearing before a Federal agency or program will be ineligible to participate in this demonstration project.

Representational Experience
All participants in the demonstration project (with or without a bachelor's degree) must have demonstrated experience in representing claimants before SSA. Applicants must meet the following minimum representational experience requirement:

The applicant must have provided representational services as the appointed representative for five claimants within a 24-month period;
Representing a claimant before SSA can count toward satisfaction of the representational requirement only if the applicant was serving as the claimant’s appointed representative at the time at which SSA decided the case at any administrative level (i.e. the initial, reconsideration, ALJ hearing, or Appeals Council level) or, if the case has not been decided while the applicant was the appointed representative, the applicant appeared as the claimant’s appointed representative at a hearing before an ALJ;

The 24-month period must occur within the 60 months preceding the month in which the application was filed.

The following is an example of how to calculate the 24- and 60- month periods for establishing representational experience:

The applicant files his or her application in June 2005.

The 60-month period begins on July 18, 2000, and ends on July 17, 2005 (the last day of the month before the filing of the application).

The 24-month period can occur at any time between July 18, 2000, and July 17, 2005. For example, the applicant would meet the requirement if he or she served as the appointed representative for five separate claimants during the period from January 2001 through December 2002.

Applicants are required to submit with their applications the names and the complete Social Security numbers of five claimants for whom the applicant provided representational services during the appropriate 24-month period. An applicant will not be required to provide additional information regarding the services provided a named claimant if the applicant provides a copy of any one of the following that the applicant received as the appointed representative of that claimant during the relevant 24-month period: a notice of either an initial determination, a reconsideration determination, an ALJ hearing, an ALJ decision, or an Appeals Council decision. If the applicant is unable to provide a copy of one of the specified notices with respect to a named claimant, the applicant will be asked to provide additional information regarding the dates and administrative level of the representational services provided that claimant. You may not list a claimant unless:

1. You were the appointed representative of the claimant at the time at which SSA decides the case at any hearing level (initial, reconsideration, ALJ hearing, Appeals Council);

2. In cases that have not been finally decided, you appeared as the claimant’s representative at a hearing before an ALJ.

Types of Insurance
Non-attorney participants are required to have professional liability insurance, or equivalent insurance, which the Commissioner has determined to be adequate to protect claimants in the event of malpractice by the non-attorney representative. This insurance policy must be underwritten by a firm that is licensed to provide insurance in the State in which the non-attorney representative conducts business. The policy must also provide coverage for professional liability insurance claims made in those States in which the non-attorney representative represents claimants before SSA.

An individual must carry professional liability insurance coverage of at least $100,000 per incident and an annual aggregate coverage of $500,000. Under a business policy, the minimum per incident coverage is $100,000 and the minimum annual aggregate coverage required is determined in accordance with the following schedule:

• For 1-10 employees covered, a minimum aggregate amount of $500,000

• For 11-25 employees covered, a minimum aggregate amount of $1 million

• For 25-50 employees covered, a minimum aggregate amount of $2 million

• For 51-100 employees covered, a minimum aggregate amount of $3 million

• For 101-200 employees covered, a minimum aggregate amount of $4 million

• 201 or more, a minimum aggregate amount of $5 million.

An applicant who fails to submit proof of the required insurance before the application period closes shall be precluded from establishing, based on his or her current application, eligibility to take the examination and to participate in the demonstration project. However, the applicant may re-apply to participate in the demonstration project during a subsequent application period.

Non-attorney representatives who establish eligibility to participate in the demonstration project will be required to maintain their insurance coverage in order to continue to receive direct fee payments from SSA.

REMEMBER, your liability insurance must be current for you to be eligible to participate in the demonstration project. For example, if you take the exam on June 7, 2006 and your insurance lapses on July 1, 2006. You are notified on July 17, 2006 that you achieved a passing score. You will not be eligible to participate in the demonstration project, regardless of your test score, until you notify us that you have again obtained the necessary liability insurance and we verify that your coverage meets minimum demonstration project requirements.

Background Check
A background check is required of each non-attorney representative who applies to participate in the demonstration project to ensure his or her fitness to practice before SSA. SSA will reject any applicant who:

• Has been suspended or disqualified from practice before SSA;

• Has had a judgment or lien assessed against him/her by a civil court for malpractice and/or fraud;

• Has had a felony conviction;

• Engages in substantial misrepresentation in submitting his or her application and/or supporting materials for the application;

• Fails to pass an SSA administrative records check (check of SSN, etc.); or

• Fails to provide documentation as requested by CPS Human Resource Services to perform the criminal background investigation.

Examination
Applicants are required to pass an examination testing their knowledge of the relevant provisions of the Act and the most recent developments in Agency and court decisions affecting titles II and XVI of the Act. The examination is a 40 to 50 question, multiple choice examination. Examination details are as follows:

• The examination instrument will be written in the English language only;

• CPS Human Resource Services will be administering the examination which will be given only once, on a weekday, in association with each application period;

• During the examination, test-takers will have open-book access to certain reference materials that we will supply (see below for details);

• The examination will be based upon situations that arise from the subject areas contained in the reference materials; and

• Applicants will not be permitted to remove the examination instrument or reference materials from the examination center.

Open-book reference materials: CPS will provide one copy of the 20 C.F.R., Chapter III (Parts 400-499) to each person taking the examination. In addition, though not required for the examination, CPS will provide two copies of the Compilation of Social Security Laws, Volume 1 at each test location. We may provide additional materials; if so, we will provide details about the materials on the CPS Human Resource Services website. Applicants will not be permitted to bring any other items (including reference materials) to the examination center.

An applicant who fails to achieve a passing score may re-apply to participate in the demonstration project during a subsequent application period; however, they will be required to pay the application fee again.

Instructions for Completing this Form

1. Before you fill out the application, you should have the following available:

• College transcripts, to include complete address

• Your employment history for the past five (5) years

• Information on College Degree's

• Names and SSN's for Claimants you have represented and documents verifying your representational experience, if available.

• Your professional or business liability insurance policy

2. Please type or print legibly using only a BLUE or BLACK ink pen.

3. All sections of this form must be filled out completely. If no response is necessary or applicable, indicate this on the form (e.g. "None" or "N/A").

4. All telephone numbers must include area codes.

5. All addresses must include Zip Codes.

6. Please list full middle name unless asked specifically for middle initial. If you do not have a middle name, please indicate this by supplementing "NMN" for a middle name.

7. All dates provided on this form must be in Month/Day/Year or Month/Year format. Use numbers (01-12) to indicate months. For example, April 3, 1979, should be written as 04/03/1979. If you cannot report the exact date, please indicate with "EST."

8. The preferred method of payment is by credit card. Please register an account on our website at http://www.cps.ca.gov/ssa/signin.asp. Once you have successfully registered, you will have the option to pay by credit card.

9. Any changes you make to your application must be lined out and initialed.

10. If you require additional space, please use Section E. Please indicate the section and question number you are responding to before you identify additional info.

Form Approved OMB No. 0960-0699

Expires XX/XX/XX

Application Fee Statement
**The application fee is generally non-refundable**
Please initial indicating that you have read and understand the statement regarding the application fee:					Initials
Preliminary Questions
1.	Are you a licensed or practicing attorney?	Yes	No
2a.	Do you have a bachelor’s degree? (If Yes, please skip question 2b. If No, please answer question 2b.)	Yes	No
2b.	Do you have equivalent qualifications? (Only respond if you answered No to question 2a.)	Yes	No
3.	Can you pass all aspects of the required background check?	Yes	No
4.	Have you ever had a felony conviction?	Yes	No
5.	Have you ever been suspended or disqualified from practice before the Social Security Administration?	Yes	No
6.	Have you had a judgment or lien assessed against you by a civil court for malpractice and/or fraud?	Yes	No
In addition, you must submit, before the close of the application period, proof that you have adequate professional liability insurance or equivalent insurance (such as business liability insurance). For further information see the application instructions. Please read the instructions on pages 1 through 3 of this application for eligibility requirements. If you answered “No” to questions, 2, or 3, you are not eligible for the SSA Non-Attorney Demonstration Project. If you answered “Yes” to questions 1, 4, 5, or 6, you are not eligible for the SSA Non-Attorney Demonstration Project.
Privacy Act Statement
The information requested on this application 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 application for participation in the demonstration project authorized by section 303 and permit a determination about your eligibility to receive direct payment of fees (from a claimant's past-due benefits) for your representation services. Information requested on this application is voluntary. However, if you do not provide the required information, a decision based on the evidence in your application file can result in a determination that you are ineligible for direct payment of fees. While the information you furnish on this application would almost never be used for any purpose other than making a determination about your 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:				Initials
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 30 - 60 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED APPLICATION TO CPS HUMAN RESOURCE SERVICES. You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD  21235-6401.  Send only comments relating to our time estimate to this address, not the completed form.
Please initial indicating that you have read and understand the Paperwork Reduction Act Statement:				Initials

SECTION A

Background Information - Applicant’s Identifying Information

First Name:

Full Middle Name:

Last Name:

Suffix:

Previous Name(s) Used:

Reason(s) for previous name(s) used:

SSN: - -

Date of Birth (mm/dd/yyyy):

Citizenship Status:

U.S. Citizen

Naturalized Citizen

Alien authorized to work in the U.S.

Other

If other, please specify:

U.S. Residency Status (if non-citizen):

U.S. Resident

Other (please specify):

Employer Identification Number (EIN), if applicable:

Taxpayer Identification Number (TIN), if applicable:

SECTION A

Background Information - Contact Information

Address:

Home Phone: ( )

Address (Line 2):

Mobile Phone: ( )

City:

State

Zip Code

Work Phone: ( )

Would you like to be notified of the exam via e-mail?

Yes

No

E-mail Address:

SECTION A

Background Information - Work History

Please provide employer and/or self-employment information for positions held during the past 5 years beginning with the current or most recent. Please account for all periods of unemployment. For periods of unemployment enter the word "unemployed" in the Position/Title field and provide From and To Dates only. You must account for the last 5 continuous years from the date of the application, regardless of its relevance to the demonstration project. Failure to identify all work within the past 5 years will result in your application being denied as incomplete.

1.

Position/Title

From (mm/yyyy):

To (mm/yyyy):

Position Description:

Name of Employer:

Employer Address:

City:

State:

Zip Code:

Name of Supervisor:

Employer Phone: ( )

SECTION A		Background Information - Work History (Continued)
2.	Position/Title		From (mm/yyyy):			To (mm/yyyy):
	Position Description:
	Name of Employer:
	Employer Address:
	City:			State:			Zip Code:
	Name of Supervisor:			Employer Phone: ( )
3.	Position/Title		From (mm/yyyy):			To (mm/yyyy):
	Position Description:
	Name of Employer:
	Employer Address:
	City:			State:			Zip Code:
	Name of Supervisor:			Employer Phone: ( )
4.	Position/Title		From (mm/yyyy):			To (mm/yyyy):
	Position Description:
	Name of Employer:
	Employer Address:
	City:			State:			Zip Code:
	Name of Supervisor:			Employer Phone: ( )
5.	Position/Title		From (mm/yyyy):			To (mm/yyyy):
	Position Description:
	Name of Employer:
	Employer Address:
	City:			State:			Zip Code:
	Name of Supervisor:			Employer Phone: ( )

SECTION A

Background Information - Work History (Continued)

6.

Position/Title

From (mm/yyyy):

To (mm/yyyy):

Position Description:

Name of Employer:

Employer Address:

City:

State:

Zip Code:

Name of Supervisor:

Employer Phone: ( )

If you require additional space, please use Section E or attach supplemental pages available at www.cps.ca.gov/tlc/ssa/resources.asp.

SECTION A

Background Information - Additional Information

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?

Yes

No

If Yes, please provide the following information:

Name of Court:

2. Have you been, by reason of misconduct, disbarred or suspended from any court or bar to which you were previously admitted to practice?

Yes

No

If Yes, please state whether you were disbarred, suspended, or resigned in lieu of disciplinary proceedings:

Details:

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?

Yes

No

If Yes, please provide the following information:

Name of Program or Agency:

Address of Program or Agency:

Details of Disqualification, Sanction or Suspension:

Date of disqualification, sanction or suspension:

Date of Reinstatement (if applicable):

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?

Yes

No

If Yes, please provide the following information:

Name of Program or Agency:

Address of Program or Agency:

Details of Investigation:

Date of Investigation:

Status of Investigation:

SECTION A

Background Information - Additional Information (Continued)

5.  Have you had a judgment or lien assessed against you by a civil court for malpractice and/or fraud?

Yes

No

If Yes, explain the circumstances. You may submit additional explanatory documents with your other application materials.

Circumstances:

6. Have you been determined to have fraudulently used or misused any Social Security benefits?

Yes

No

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?

Yes

No

8. Can you pass all aspects of the required criminal background check, including a Social Security records check?

Yes

No

9. Have you applied for the SSA Non-Attorney Representative Examination before?

Yes

No

If Yes, please provide the following information:

Date of Previous Application(s):

Disposition of Previous Application:

Any Changes to Report Since Previous Application:

SECTION B

Representation of Claimant Information

Please provide information for 5 Claimants represented within 24 consecutive months during the past 5 years. You may not list a claimant unless: You were the appointed representative of the claimant at the time at which SSA decided the case at any administrative level (initial, reconsideration, ALJ hearing, Appeals Council); or In cases that have not been finally decided, you appeared as the claimant's representative at a hearing before an ALJ.

1.

Claimant’s First Name

Claimant’s Last Name

Claimants Full SSN: - -

You will not be required to provide the additional information below if you can provide a copy of any one of the following that you received as an appointed representative of this claimant during the relevant 24 month period: a notice of either an initial determination, a reconsideration determination, an ALJ hearing that was held, an ALJ decision, or an Appeals Council decision.

Are you providing copies of documents to prove representational experience?

Yes

No

Date Appointed (mm/dd/yyyy):

Date Representation Ended (mm/dd/yyyy):

Appeal Level:

Date of Hearing (mm/dd/yyyy):

Did you receive a notice of an initial or reconsideration determination, an ALJ hearing, or an ALJ or Appeals Council decision as an appointed representative of the claimant? If so, enter the latest such notice you received and the date you received it.

Yes

No

Type of Notice:

Notice Date (mm/dd/yyyy):

SECTION B

Representation of Claimant Information (Continued)

2.

Claimant’s First Name

Claimant’s Last Name

Claimants Full SSN: - -

You will not be required to provide the additional information below if you can provide a copy of any one of the following that you received as an appointed representative of this claimant during the relevant 24 month period: a notice of either an initial determination, a reconsideration determination, an ALJ hearing that was held, an ALJ decision, or an Appeals Council decision.

Are you providing copies of documents to prove representational experience?

Yes

No

Date Appointed (mm/dd/yyyy):

Date Representation Ended (mm/dd/yyyy):

Appeal Level:

Date of Hearing (mm/dd/yyyy):

Did you receive a notice of an initial or reconsideration determination, an ALJ hearing, or an ALJ or Appeals Council decision as an appointed representative of the claimant? If so, enter the latest such notice you received and the date you received it.

Yes

No

Type of Notice:

Notice Date (mm/dd/yyyy):

3.

Claimant’s First Name

Claimant’s Last Name

Claimants Full SSN: - -

You will not be required to provide the additional information below if you can provide a copy of any one of the following that you received as an appointed representative of this claimant during the relevant 24 month period: a notice of either an initial determination, a reconsideration determination, an ALJ hearing that was held, an ALJ decision, or an Appeals Council decision.

Are you providing copies of documents to prove representational experience?

Yes

No

Date Appointed (mm/dd/yyyy):

Date Representation Ended (mm/dd/yyyy):

Appeal Level:

Date of Hearing (mm/dd/yyyy):

Did you receive a notice of an initial or reconsideration determination, an ALJ hearing, or an ALJ or Appeals Council decision as an appointed representative of the claimant? If so, enter the latest such notice you received and the date you received it.

Yes

No

Type of Notice:

Notice Date (mm/dd/yyyy):

4.

Claimant’s First Name

Claimant’s Last Name

Claimants Full SSN: - -

You will not be required to provide the additional information below if you can provide a copy of any one of the following that you received as an appointed representative of this claimant during the relevant 24 month period: a notice of either an initial determination, a reconsideration determination, an ALJ hearing that was held, an ALJ decision, or an Appeals Council decision.

Are you providing copies of documents to prove representational experience?

Yes

No

Date Appointed (mm/dd/yyyy):

Date Representation Ended (mm/dd/yyyy):

Appeal Level:

Date of Hearing (mm/dd/yyyy):

Did you receive a notice of an initial or reconsideration determination, an ALJ hearing, or an ALJ or Appeals Council decision as an appointed representative of the claimant? If so, enter the latest such notice you received and the date you received it.

Yes

No

Type of Notice:

Notice Date (mm/dd/yyyy):

SECTION B

Representation of Claimant Information (Continued)

5.

Claimant’s First Name

Claimant’s Last Name

Claimants Full SSN: - -

You will not be required to provide the additional information below if you can provide a copy of any one of the following that you received as an appointed representative of this claimant during the relevant 24 month period: a notice of either an initial determination, a reconsideration determination, an ALJ hearing that was held, an ALJ decision, or an Appeals Council decision.

Are you providing copies of documents to prove representational experience?

Yes

No

Date Appointed (mm/dd/yyyy):

Date Representation Ended (mm/dd/yyyy):

Appeal Level:

Date of Hearing (mm/dd/yyyy):

Did you receive a notice of an initial or reconsideration determination, an ALJ hearing, or an ALJ or Appeals Council decision as an appointed representative of the claimant? If so, enter the latest such notice you received and the date you received it.

Yes

No

Type of Notice:

Notice Date (mm/dd/yyyy):

SECTION C

Education/Equivalent Qualifications – Colleges/Universities Attended

Please provide information on the accredited Colleges or Universities that you have attended. For each College or University you enter, you must also provide proof in the form of an official transcript showing the stamp or raised seal, or otherwise establishing that it is an official copy. If you have a bachelor's degree or higher, you need only enter and provide proof for the College or University from which you graduated.

If you require additional space, please use Section E or attach supplemental pages available at www.cps.ca.gov/tlc/ssa/resources.asp.

Name of College/University:

City:

State:

Attended From (mm/yyyy):

Attended To (mm/yyyy):

Degree Granted?

Yes

No

Indicate degree granted or years of study:

Graduate Degree

Bachelors Degree

At least three (3) years of undergraduate study

At least two (2) years of undergraduate study

At least one (1) year of undergraduate study

Less than one (1) year of undergraduate study

Name of College/University:

City:

State:

Attended To (mm/yyyy):

Attended To (mm/yyyy):

Degree Granted?

Yes

No

Indicate degree granted or years of study:

Graduate Degree

Bachelors Degree

At least three (3) years of undergraduate study

At least two (2) years of undergraduate study

At least one (1) year of undergraduate study

Less than one (1) year of undergraduate study

SECTION C

Education/Equivalent Qualifications – High School Diploma or G.E.D.

If you do not have at least one year of undergraduate study at an accredited College or University, you must provide information on your High School Diploma or G.E.D. You must also provide proof in the form of a copy of your high school transcripts, diploma, or G.E.D certificate (or other equivalent documentation).

High School or G.E.D. Institution:

City:

State:

Date Diploma or Certificate Awarded (mm/yyyy):

SECTION C

Education/Equivalent Qualifications – Professional Experience

If you have a bachelor's degree or higher, skip this section. If you do not have a bachelor's degree or higher, provide information on relevant professional experience. The amount of relevant professional experience you must show varies with the number of years of undergraduate study you have reported. A certain portion of that experience must be professional level work involving claims under Title II and/or Title XVI. See the instructions for more information about this requirement. In the Position Description field, you must add enough detail for SSA to determine if the cited experience constitutes relevant professional experience. If you have any questions, contact CPS toll free at (800) 376-5728.

1.

This experience is:

SSA Related Professional Experience

Other Professional Experience

Position/Title:

From (mm/yyyy):

To (mm/yyyy):

Position Description:

Name of Employer:

Address:

City:

State

Zip Code:

Name of Supervisor:

Employer Phone: ( )

2.

This experience is:

SSA Related Professional Experience

Other Professional Experience

Position/Title:

From (mm/yyyy):

To (mm/yyyy):

Position Description:

Name of Employer:

Address:

City:

State

Zip Code:

Name of Supervisor:

Employer Phone: ( )

If you require additional space, please use Section E or attach supplemental pages available at www.cps.ca.gov/tlc/ssa/resources.asp.

SECTION D

Examination Information

The exam will be administered in 10 locations across the country. The exam will be held on the same date at each location. CPS may cancel any site if enrollment does not meet minimum standards. In that event, applicants will be notified at least 30 days prior to the test date in order to select another active test site and make appropriate travel arrangements. The following cities are currently planned to host the exam administration:

Austin, Texas Chicago, Illinois Nashville, Tennessee

Philadelphia, Pennsylvania Sacramento, California Tampa, Florida

Detailed information concerning the specific location of the examination site will be mailed to those applicants determined eligible to sit for the examination. Visit www.cps.ca.gov for more information.

SECTION D

Examination Information – Location Request

Applicants will be asked to select a first and second choice for their examination site (for use if they meet all of the prerequisites and are eligible to sit for the exam). Applicants who timely submit their applications but fail to select a second choice will have their applications denied as incomplete. Applicants who timely submit their applications but repeat their first choice as their second choice will be contacted and given the opportunity to cure the defect by selecting a second choice examination site that is different from the first choice examination site. This information will be used by SSA in the event the first choice examination site is cancelled. Please provide your top two (2) choices for your examination location.

First Choice Location:

City:

State:

Second Choice Location:

City:

State:

SECTION D

Examination Information – Special Accommodation Request

Please describe any special accommodation you will need at the examination location. Please note that you must provide supporting documentation from a professional qualified to determine your condition.

Initial indicating that you understand that you must provide written documentation to support your request:

Initials

SECTION E	Additional Information

	Substantial Misrepresentation or Material Discrepancy
If I cannot substantiate my application or it is determined that the information I entered is incorrect, I understand that I may be determined ineligible for the Demonstration Project, either to begin with or, if I am found eligible, after I begin to participate in the project.
Please initial indicating that you have read and understand the Substantial Misrepresentation or Material Discrepancy statement:								Initials
		Statement of Understanding
I understand that I must submit my online application, print a copy, sign the copy in ink, include all supporting documentation along with the application fee, and send or deliver the complete application package to the address below. I also understand that I will be required to complete, sign and submit a release form necessary for the criminal background check with this application. CPS Human Resource Services Attn: SSA Demonstration Project 241 Lathrop Way Sacramento, CA 95815 This application package must be postmarked or receipt-dated (if sent by private express service) by midnight E.D.T. March 15, 2007. If hand-delivered, the application must be received at the above address by 5:00 p.m. P.D.T. March 15, 2007. I further understand that the application fee is generally non-refundable. CPS will not process my application until the completed application package, including all supporting documentation, is received. If this requirement is not met as of midnight E.D.T. March 15, 2007, SSA will process your application as a denial.
Please initial indicating that you have read and understand the Statement of Understanding statement:								Initials
			Penalty of Perjury Statement
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. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.
Signature (sign in ink):					Date:

Form Approved OMB No. 0960-0699

Expires 02/29/08

		Supporting Documentation
Please provide CPS information about your personal professional liability insurance or equivalent insurance (such as business liability insurance). You must provide a copy of your insurance policy or binder of insurance. Although providing this information is voluntary, failure to provide the information will cause the Social Security Administration (SSA) to deny your current application to participate in the demonstration project on direct payment of fees.
Type of Policy:		Coverage:		Policy Number:			Expiration Date:
Agent Name:						Agent Phone: ( )
Insurance Company:
Address:
City:			State:			Zip Code:
The policy must provide coverage in States in which you do business, and in all States in which you represent claimants before SSA.
In which state(s) do you represent claimants before SSA?
In which state(s) are you insured to practice before SSA?
Completed Application
Before submitting your completed application package, please verify that you have included: A copy of your personal professional liability insurance or equivalent insurance (such as business liability insurance). You must provide a copy of your insurance policy or certificate of insurance; If applicable, an official college and/or university transcript(s) showing the stamp or raised seal of the institution, or otherwise establishing that it is an official copy; * If applicable, a copy of your high school transcript, diploma, or GED certificate (or other equivalent documentation);* If you did not fill out the additional information in the Representation of Claimants section for any claimant you listed as an individual you represented before SSA, you must send a copy of one of the required notices as indicated in that section; You have included a non-refundable certified check, money order, or check drawn from a private firm's account in the amount of $1,000.00 (in U.S. dollars) payable to CPS Human Resource Services. The preferred method of payment is by credit card. Please register an account on our website at http://www.cps.ca.gov/ssa/signin.asp. Once you have successfully registered, you will have the option to pay by credit card. *Note: for those individuals who have submitted otherwise complete application packages within the application period, proof of education will be considered timely if it is received by CPS no later than 5:00pm (PDT) on April 12, 2006. Please mail your completed application and accompanying documents along with your $1,000.00 application fee to:
	CPS Human Resource Services Attn: SSA Demonstration Project 241 Lathrop Way Sacramento, CA 95815

Form Approved OMB No. 0960-0699

Expires 02/29/08

ACCUSOURCE, INC.

PLEASE READ CAREFULLY

Under section 303 of the Social Security Protection Act of 2004 (2004), the Social Security Administration (SSA), with the assistance of CPS Human Resource Services (CPS), is conducting a demonstration project on direct payment of representative fees to eligible

non-attorney representatives. SSPA section 303(b) provides that an individual may not be found eligible to participate in the demonstration project without undergoing a criminal background check to ensure the individual’s fitness to practice before SSA. All individuals applying to participate in this demonstration project are required to consent to a criminal background check that will be conducted for SSA and CPS by our firm, ACCUSOURCE, INC. (henceforth, AccuSource). Our address and telephone number are 1240 E. Ontario Avenue, Suite 102-140, Corona, California 92881, 951-734-8882.

APPLICANT AUTHORIZATION FOR RELEASE OF INFORMATION

I authorize AccuSource to conduct a criminal background check in which AccuSource may secure any criminal history information pertaining to me that may be in the files of any Federal, State, or Local criminal justice agency. I authorize any Federal, State, or Local criminal justice agency to release to AccuSource any criminal history information pertaining to me that may be in the agency’s files. I authorize AccuSource, and any of its agents, to disclose orally and in writing the results of this criminal background check to CPS and SSA.

I understand that the results of the criminal background check may be used by SSA to determine my eligibility for the demonstration project on direct payment of fees, and may not otherwise be used except as authorized by law. In the event that SSA uses information from the criminal background check in whole or in part in making an adverse decision with regard to my eligibility to participate in the project, I understand that CPS will provide me a copy of the report on the criminal background check submitted by AccuSource and a description in writing of my right to protest the decision to SSA.

I understand that submission of this authorization is voluntary. I also understand that failure to provide the authorization and information required to conduct a criminal background check will cause SSA to deny my application.

I understand that copies of this authorization that show my signature are as valid as the original, and that this authorization is valid for

6 months from the date signed.

CRIMINAL BACKGROUND CHECK INFORMATION

Applicant Last Name First Name Middle Name

List Other Names Used Date of Birth Social Security Number

Please List all the addresses you have lived at in the last 5 years

Current Address City/State/Zip Dates

Previous Address City/State/Zip Dates

Previous Address City/State/Zip Dates

Previous Address City/State/Zip Dates

SIGNATURE

_____________

Applicant’s Signature Today’s Date Daytime Phone

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