Currently Approved Non-Attorney Representative Application

Currently Approved
Non-Attorney Representative
Application

Currently Approved
Non-Attorney Representative
Application

Social Security Administration
Non-Attorney Representative Demonstration Project
You must complete this application carefully and provide aJI 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 I -800-376-5728.
during the next application phase, but they will pay the
Purpose of this Form
full fee upon reapplying.
Section 303 of the Social Security Protection Act of 2004
SSPA Public Law no.108-203 provides for a 5-year
The fee will be non-refundable except in the following
demonstration project to be conducted by SSA under
circumstance: If CPS fails to adminisler a scheduled
which the direct payment of SSA-approved fees is
examination: CPS will be required to refund the fee to
extended to certain non-attorney claimant
those affected appficants who do not take the
representatives. Under the SSPA, to be eligible for direct
rescheduled examination
payment of fees, a non-attorney representative must
fulfifi the following statutory requirements: I Possess a
Education and Equivalent Qualifications
bachelors degree or have equivalent qualifications
A bachelor’s degree from an accredited institution of
derived from training and work experience; 2 pass an
higher education has been established as a prerequisite
examination that tests knowledge of the relevant
for participating in the demonstration project. However,
provisions of the Social Security Act; 3 secure
applicants who do not have a bachelor’s degree may
professional liability insurance or equivalent insurance;
satisfy this prerequisite based on combinations of
4 pass a background check; and 5 demonstrate
training and work experience that the Commissioner
completion of relevant continuing education courses.
determines to be equivalent to a bachelor’s degree. We
have determined that any of the following combinations
Section 303b of the SSPA permits the Commissioner
of education and experience shall be equivalent to
of Social Security to establish additional prerequisites.
having a bachelor’s degree:
Pursuant to that authority, the Commissioner will require
applicants to satisfy a representational experience
lithe applicant does not have a bachelor’s
requirement to participate in the demonstration project.
degree, but has three years or more of
undergraduate study at an accredited institution
SSA must collect the requested information to determine
of higher learning, the applicant must have at
if a non-attorney representative has met the
least one year of relevant professional
requirements to be eligible for direct payment of fees for
experience as defined below, at least six
his or her claimant representation services. The
months of which must have involved claims for
information collection is needed to comply with the
benefits under title II or title XVI of the Act;
legislation. The respondents are non-attorney
If the applicant has at least two, but less than
representatives who apply for direct payment of fees.
three years of undergraduate study at an
accredited institution of higher learning, the
SSA will collect this information through the services of a
applicant must have at least two years of
private contractor, CPS Human Resource Services.
relevant professional experience, at least one
the
process
for
CPS is assisting SSA in administering
year of which must have involved claims for
determining eligibility of non-attorney representatives to
benefits under title II or title XVI of the Act;
participate in the demonstration project on direct
payment of fees.
If the applicant has at least one, but less than
two years of undergraduate study at an
Application Fee
accredited institution of higher learning, the
SSPA section 303c I provides that the Commissioner
applicant must have at least three years of
may assess applicants a reasonable fee to cover the
relevant professional experience, at least two
costs of administering the prerequisites process. The fee
years of which must have involved claims for
will be $1000 in U.S. dollars per applicant;
benefits under title I or XVI of the Act; or
Applicants must include the fee payment with their

If the applicant has less than one year of

application package;

undergraduate study at an accredited institution
of higher learning, or no undergraduate

Acceptable forms of fee payment will be by certified
check, money order, a check drawn from a private firms
account, or credit card;
Applicants will pay their fees to CPS Human Resource
Services; and
Applicants who are not found to be eligible may reappty
Page 1

education, the applicant must have received a
high school diploma or CEO 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 bachelors
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 1631d2 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;
The services may include representing the claimant at
the time at which SSA decided the case at any
administrative level or, in cases that have not yet been
decided, appearing as the claimant’s representative at a
hearing before an SSA Administrative Law Judge AU;
and
The 24-month period must occur within the 60 months
preceding the month in which the application was filed.
The following san example of how to calculate the 24and 60- month periods for establishing representational
experience:
The applicant files his or her application in March 2005.
The 60-month period begins on March 1, 2000, and
ends on February 28, 2005 the last day of the month
before the filing of the application.
Page 2

The 24-month period can occur at any time between
March 1. 2000, and February 28, 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 last four digits of
the 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 AU hearing, an AU decision, or an
Appeals Council decision. Notices of determinations or
decisions submitted may be of favorable, partially
favorable or unfavorable determinations or decisions.
Applicants will be asked to redact copies of notices
submitted to show only the last four digits of the
claimant’s Social Security number. 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.
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. SSA has determined that
applicants must have professional liability insurance for
coverage of errors and omissions committed by the nonattorney representative, with a minimum total annual
amount of coverage of $1 million for all incidents in that
year plus coverage of $100,000 per incident. The
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 also must provide coverage for professional
liability insurance claims made in those States in which
the non-attorney representative represents claimants
before SSA.
Business liability insurance will suffice in place of
personal professional insurance, if the business
insurance provides protection for the claimant equaling
that provided under the requirements established for
personal professional insurance. Thus, for example.
since the standards for personal insurance will require
minimum annual coverage of $1 milrion for all incidents
in a year and $100,000 per incident, a business policy
covering five non-attorney representatives would have to
provide, to satisfy the insurance prerequisite, minimum
annual coverage of $5 million for all incidents by the 5
representatives in a year, plus $100,000 per incident
involving the covered representatives.

An applicant who faUs to submit proof of the required
insurance before the application period closes shall be
precluded from establishing, based en 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.
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 materi&s 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
heir knowledge of the relevant provisions of the Act and
he 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:
*
*
*

*
*
*

A score of 70 percent will be a passing score;
The examination instrument will be written in the
English language only;
We anticipate that the examination will be
administered by CPS Human Resource Services
and 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 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
Page 3

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 Web site. 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
familiarize yourself with the entire application, in
addition, you should have the foHowing available:
*
*
*
*

Your employment history for the past five years
Information about claimants you have
represented before SSA in the pastS years
Information about your education or equivalent
professional experience
Your personal or business liability insurance
policy or insurance binder

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. lino response is necessary or
applicable, indicate this on the forni e.g. "None" or
‘N/A.
4. All telephone numbers must include area codes.
5. All addresses must include Zip Codes.
6. Please list thu middle name uniess 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 $1,000.00 application fee is non-refundable
except under the circumstance specified on page 1
of these instructions.

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

10. If you require additional space, please use
Section E-1. Please indicate the section and
question number you are responding to before you
identify additional information.

Page 4

Form Approved 0MB No, 0960-0699
Expires ft2/29/O8
Application Fee Statement
**The application fee is non-refundablr
Initials

-

Please initial indicating that you have read and understand the statement regarding the application fee:
Preliminary Questions
1. Are you a licensed or practicing attorney?

U Yes

0 No

2, Do you have a bachelors degree or equivalent qualifications?

U Yes

U No

3. Can you pass all aspects of the required background check?

U Yes

U No

4. Have you ever had a felony conviction?

U Yes

U No

5. Have you ever been suspended or disqualified from practice before the Social
Security Administration?

U Yes

0 No

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

U Yes

U 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 tot 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 applicationS
file can result in a determination that you are ineligible for direct payrrent 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 compEy with laws and regulations requiring the exchange of information between SSA and another agency.
Initials
Please initial indicating that you have read and understand the Privacy Act Statement:
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, 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments
relating to our time estimate to this address.
InitiIs

Please initial indicating that you have read and understand the Paperwork Reduction Act Statement:

Page 5

SECTION A
First Name:

Background Information Applicant’s Identifying Information
-

ITlJuk’4 Udle Name:

Lass Name:

i.

P,oviuus Names Used:
Reasons for previous names used:

SSN:

Date of BirTh mrn/dd/’’:

Citizenship Status:
U

U.S. Citizen

U Alien authori ed to

U Naturalized CiUzen

U Other

If other, pFease specify:
U.S. Rosidency Status if non-citizen:
U

U.S. Resident

U Other please specify:

Employer Identification Number EIN,
if applicable:
Taxpayer Identification Number TIN,
if applicable:
SECTION A
Background Information Contact Information
-

Address:

Hone Phone:

Address Line 2:

Work Phone:

City:

State

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

Zip Code

E-mail Address:

U Yes

U No

SackgrounU Information Work History
-

Please provide employer andlor 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 lastS continuous
years from the date of the application.
1.

PositFonITitIe

From mrTy:

To mnVyy:

Position Deswiption:

Name of Employer
Employer Address:
City:

State:

Nane of Supervisor:

Employer Phone:

Page 6

Zip Code:

SECTION A
2.

Background Information Work History Continued
-

PosaioniTitle

To mrn/yvyy:

mmlyyyy:

Postlion Descrlpt!on:

Name of Employer:
Employer Address:
City:
Name of Supervisor:
3.

Posifion/Title

State:
- - -

-

From rn i.-:

Zp Cr:d

Eji plc: ,tr lI.

--

To rnnilyyyy:

yy

Position Description:
Name of Employer:
Employer Address:

4.

City:

State:

Name of Supervisor:

Employer Phone:

Position/TItle

From mrnlyyyy:

Zip Code:

To mrrV%y:

Position Desciiption:
Name of Employer:
Employer Address

5.

City

State:

Name of Supervisor

Employer Phone:

PositionJTiue

From mmyyy:

ZipCode.

To mm/ygy’:

Position Description:
Name of Employer:
Employer Address:
City:

State:

Name of Supervisor:

Employer Phone:

Page 7

Zip Code:

SECTION A

6,

Background Information

Work History Continued

-

lip.."

Position/Title

To mm!yyyy:

Posit[on Description:
Name of Employer:

--

Employer Address:

-

-

City:

State:

N2me of Supervisor

Employer Phone:

Zip Code:

If you require addiuonal space, please use Section E or attach supplemental pages available at www.s.ca.gov

SECTION A

Background

Information

-

Additional

Information

I. Have you ever been employed by the Social Security Administration SSA or
any other Federal, State, local or tribal government entity department, agency,

0 Yes

U No

bureau, etc.?

If Yes, please provide the
following information:

Name of Entity:

Job Title:

Name of Office:

Date of Last Employment:

Reason Employment Ended:

- - -

2. Has the SSA or any other Federal, Stale, local or tribal government enflty
department, agency, bureau, etc. ever suspended or disqualified you as an
agent or representative?
Name of Entity:

U Yes

U No

Address of Entity:

Details of the Suspension:

If Yes, please provide the
following information:

Date of Suspension or Termination:

3. Have you ever had a judgment
for Malpractice and/or fraud?

or lien assessed against you

Date Df Reinstatement it appJicable:

by

Type of Case:

a

Civil

Court

CS
Court ot Judsdiction:

Offense Involved:

If Yes, please provide the
following information:

Judgment:
Circumstances Surrounding the Case:

Page 6

Date of Court’s Final Decision:

N0

SECTION A
Background Information Additional Information Continued
4. Have you ever been convicted of
or pled guilty or nob contenders to a
0 Yes
U No
felony?
-

Court of Jurisdiction:
If Yes, please provide the
following information:

Offense lnvoved:

Date of Conviction or Nob Conteridere Plea:
Indicate if Currently on Probation or Under Court-Imposed Supervision:

5. Have you ever been suspended or disbarred by any bars or Courts before
which you have been admitted to practice?
Courts or Bars that took Aclions:

U Yes

U No

Dates Actions Taken:
Reason for Actions:

If Yes, please provide the following
information:

Dates and Circumstances of Reinstatement if any:

6. Have you ever applied to take the SSA Non-Attorney Representative
Examination before?

Yes

U

No

Date of Previous Applications:
Disposition of Pre’.4ous Application:

If Yes, please provide the following
information:

SECTION 0

Jly Changes to Repod Since Previous Application:

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, AU hearing, Appeals Council; or
In cases that have not been finally decided, you appeared as the claimant’s representative at a hearing before an

AU.
1.

Claimants First Name

Ctaimant’s Last t’Jane

Last 4 digits of 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 AU hearing that was held, an AU
decision, or an Appeals Council decision.

Page

SECTION B
Date Appointed mm/dd/my:
Appeal Level:

Representation of Claimant Information Continued
Date Representation Ended mm/dd/jyyy
Date of Hearing rnrn/dd/yyyy:

Did you receive a notice of an initial or reconsideration determination, an AU

hearing, or an AU 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.
Type of Notice:
2.

Claimants First Name

es

U N0

Notice Date mm/dd/yyyy:
Claimants Last Name

Last 4 digits of 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 AU hearing that was held, an AU
decision, or an Appeals Council decision.
Date Appointed mrn/dd/yyyy}:

Date Representaon Ended mmtdd/y:

Appeal IeveI:

Date of Hearing mm/dd/yy:

Did you receive a notice of an initial or reconsideration determination, an AU
hearing, or an AU 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.
Notice Date rnm/dd/yy:
Type of Noce:
3.

Claimant’s First Name

0 Yes

0 No

Last 4 digits of SSN:

claimant’s Last Name

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 AU hearing that was held, an AU
decision, or an Appeals Council decision.
Date Representaon Ended mm/dd/nO:
Date Appointed rnrnldd/yyyy:
Appeal Level:

Date of Hearing mnl/dd/flyy:

Did you receive a notice of an initial or reconsideration determination, an AU
bearing, or an AU 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.
Type of Notice:
4.

Caimants First Name

-

U Yes

U No

Notice Date mm/ddfly:
Claimants Last Name

Last 4 digits of

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 AU hearing that was held, an AU
decision, or an Appeals Council decision,
Date Appointed rnn*dlyyyy:

Date Representation Ended mm/ddJy:

Appeal Level:

Date of Hearing mrnddMw:

Page 10

SSN:

SECTION B
Representation of Claimant Information Continued
Did you receive a notice of an initial or reconsideration determination, an AU
hearing, or an AU or Appeals Council decision as an appointed representative of
the claimant? If so, enter the latest such notice you received and the dale you
received 9.
Type of Notice:
5.

U Yes

UNo

Notice Date mm/dd/yy:

claimants First Name

Claimants Last Name

Last 4 digits of 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 AU hearing that was held, an AU
decision, or an Appeals Council decision.
Date Appointed mm/ddlyyyy:

Date Representation Ended mrTdd1yfly:

Appeal Level:

Date or Hearing mm/dd/yy:

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

U Yes

U No

Notice Date mrnfdd/yyyy:

SECTION C

EducationEquivalent 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.
Name of College/University:
City:
State:
Attended From mr,Vy;

Attended To mnVyyyy:

Degree Granted?

U Graduate Degree

I
U

U Yes

No

Bachelors Degree

U At least threeS years of undergraduate study
Indicate degree granted or years of
study:

U At least two 2 years of undergraduate study
U At least one 1 year of undergraduate study
U Less than one I year of undergraduate study

Name ot College/University:
Attended To mSyy:

City:
Attended To mmlyyyy:

Degree Granted?

U Graduate Degree

State:
I

U Yes
‘U Bachelors Degree

U At least threeS years of undergraduate study
Indicate degree granted or years of
study:

U At least two 2 years of undergraduate study

o

At least one 1 year of undergraduate study

U Less than one 1 year of undergraduate study
If you require additional space, please use Section E or attach supplemental pages available at www.s.capov
Page 11

U No

SECTION C

EducationlEquivalent 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 C.E.O certificate or other equivalent documentation.
High School or G.E.D. Institution;
City:

State:

-

SECTION C

EducatlonEquivalent Qualifications

-

DaMe DipI-na or Certilicate Awarded mrWyg:

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 professionai lever 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:
Position/Tide:

U SSA Related Professional Experience

0 Other Professional Experience
To mnt’yg:

From mrnfyyyy:

Position Description:

Name of Employer;
Address:

2.

City:

State

Name of Supervisor:

Employer Phone:

This experience is:
Positionrritle:

U SSA Related Professional Experience

Zp Code:

0 Other Professional Experience
To mm/iyy:

From mrTVyyyy;

Position Description:

Name of Employer:
Address:
City:

State

Name of Supervisor:

Employer Phone;

Zip Code:

If you require additional space, please use Section E or atlach supplemental pages available at www.cos.capov

Page 12

SECTION 13

Examination Information

The exam will be administered in 10 locations across the country. The exam wilt 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 lest 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:
*
*
*

Boston, Massachusetts
New York, New York
Philadelphia, Pennsylvania

*

Atlanta, Georgia

*

Chicago, Illinois

*
*
*
*
*

Dallas-Fort Worth, Texas
St. Louis, Missouri
Denver, Colorado
Los Angeles! California
Seattle, Washington

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

Examination Information

-

Location Request

Please provide your top two 2 choices for your examinaUon location.
City:

State:

First Choice Location:
Second Choice Location:

SECTION 0

I City:
Examination Information

--

-

F State:

Special Accommodation Request

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

Inibals

Initial indicating that you understand that you must provide written documentation to support your request:
Page 13

SECTION E

Page 14

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 lam 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

IrlitraTs

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 subsequently be required to complete, sign and submit a release
form necessary for the criminal background check This form will be sent to me under separate cover.
CFS 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. April 4,2005. If hand-delivered, the application must be received at the above address by 5:00 p.m. P.D.T.
April 4, 2005. I further understand that the application fee is non-refundable. CI’S 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. April 4, 2005, SSA will process your application as a denial.
nitials

Please initial indicating that you have read and understand he Statement of Understanding statement:
Penalty of Perjury Statement
I declare under penalty of perjury that I have examined all the information on this farm, 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:

Page 15

Date:

Liability Insurance
Disclosure

Form Approved 0MB No. 0960-0699
Expires 02/29/08

4kjJ.

Li Human Resource Services

Supporting Documentation
Please provide CPS intormation about your personal protessional 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 Pojicy:
Covera9e:
Agent:

Agent Phone:

Insurance Company:
Address:

City:

State:

Up 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 states do you represent claimants before SSA?

in which states are you insured to practice before SSA?
Completed Application
Before submitting your completed application package, please verify that you have incruded:
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 binder of insurance;
V If applicable, an official college and/or university transcripts showing the stamp or raised seal of the institution, or
otherwise establishing that it is an official copy;
V If applicabre, a copy of your high school transcript, diploma, or GED certificate or other equivalent
documentation;
I 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;
V You have included a non-refundable certified check, money order, or check drawn from a private firms account in
the amount of $1000.00 in US. dollars payable to CPS Human Resource Services, or to pay by credit card,
please register an account on our website at http:/lwww.cps.ca.gov/ssa/signin.asp. Once you have successful!y
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 May 16, 2005.
Please mail your completed application and accompanying documents along with your $1000.00 application fee to:
CPS Human Resource Services
Attn: SSA Demonstration Project
241 Lathrop Way
Sacramento, CA 95815
*

Page 16

Background Check
Disclosure

Form Approved 0MB Nq. 0960-0699
Expires 02/29/08
ACCUSOURCE, INC.
PLEASE REAL CAREFULLY
Under section 303 of the Social Security Protection AOL 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 303b provides that an individual may not be found eligible to participate in the demonsiration
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 EPS
by our firm, ACCUSOURCE, INC. hcnceforlh, AccuSource, Our address and telephone number are 1240 B. 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 tome that may be in the agency’s files. I
authorize AccuSource, and any of its agents, to disclose orally and in iting the results of this criminal background check to CPS and SSA.
I understand that the results of the criminal background check maybe used by SSA to determine ny 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 pan in making an adverse decision with regard to my eligibility to participate in the project. I
understand that CPS 1l provide nic 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 ofthis authorization that show my signature are as valid as the original, and that this authorization is valid for
6 mouths 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