Current SSA-1699 screens

Appointed Representative System

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Employee: Jane S. Doe Today’s Date Is: Monday Jan 2, 2006

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Form SSA-1699 SSN	[_________] [Query] [Establish/Update]
Form SSA-W-9 EIN	[_________] [Query] [Establish/Update]
Sanctions SSN	[_________] [Query] [Establish/Update/Delete]

Request for Appointed Representative’s Direct Payment Information

Follow this link to:

• Process a paper form SSA-1699 completed by a representative.

• Query the Appointed Representative Database (ARDB) for SSA-1699 information.

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Appointed Representative System

Form 1699

Employee: Jane S. Doe Today’s Date Is: Monday Jan 2, 2006

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Personal/Professional Information

Business Affiliation Details

1699 Summary

Personal Information

Social Security Number:

123-45-6789

Name:

Andrew Allan Attorney Jr.

Tax Mailing Address:

Address Type	 U.S.	 Foreign
Street Address Line 1	[______123 Apple St______]
Street Address Line 2	[______________________]
City	[__Baltimore______]
State	[MD][V]
Zip Code	[21207]

Professional Information
Are you registering to receive payments as an attorney or an eligible for direct payment non-attorney?
 Attorney	 Eligible for Direct Payment Non-Attorney
Please provide the location and name of one court to which you have been admitted to practice law and are currently in good standing. If you are admitted to more than one court, please provide information for only one court.
Principal Location of Court: (e.g., State, Territory, or District of Columbia)		[______Virginia_________][V]
Full Name of the Court: (e.g., Supreme Court of Virginia, U.S. District Court for the Southern District of New York, U.S. Court of Appeals for the 9th Circuit)		[_Supreme Court of Virginia___][V]

Attestation:

The applicant must sign the paper application to be processed. If the applicant has done so, check the following box:

CheckBox1

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Appointed Representative Application

Form 1699

Employee: Jane S. Doe Today’s Date Is: Monday Jan 2, 2006

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AR Menu

Personal/Professional Information

Business Affiliation Details

1699 Summary

Social Security Number: 123-45-6789

Name: Andrew Allan Attorney Jr.

Business Affiliation Details

Type of Affiliation	 Sole Proprietor or Single-Member LLC/LLP			 Partner or Salaried Employee
EIN of Entity	[_________] [Lookup Name]
Name of Entity
Notice and Payment Address (Address for SSA notices and, when direct deposit does not apply, fee payment.)	Copy from Tax Mailing Address				
	 U.S				 Foreign
	Street Address Line 1		[Calle Cuatro # 21________]
	Street Address Line 2		[______________________]
	City		[Cartagena_____________ ]
	Country	[Colombia______________][V] Other [______________________]
	Postal Code		[CA-936_________]
Phone Number	 U.S			 Foreign
	[1234567890] ext: [____]
Fax Number (optional)	 U.S			 Foreign
	[123456789012345]

Payment Preference for this Affiliation:

Method of Payment	 Check	¡ Direct Deposit
Are you the owner or co-owner of this account?	¡ Yes	No
Nine-Digit Routing Number	[_______________]	[Lookup Financial Institution]
Name of Financial Institution
Type of Account	Checking	¡ Savings
Account Number	[_______________]

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Appointed Representative System

Form 1699

Employee: Jane S. Doe Today’s Date Is: Monday Jan 2, 2006

Help  PolicyNet 

Social Security Number:

123-45-6789

Name:

Andrew Allan Attorney Jr.

Business Affiliation Details

Type of Affiliation	 Sole Proprietor or Single-Member LLC/LLP	 Partner or Salaried Employee
EIN of Entity	[111111111] [Lookup Name]
Name of Entity	Binder and Binder
Notice and Payment Address (Address for SSA notices and, when direct deposit does not apply, fee payment.)	Copy from Tax Mailing Address		CheckBox1
	 U.S		 Foreign
	Street Address Line 1			[____ 123 Frederick Rd___]
	Street Address Line 2			[______Suite 102________]
	City			[__Baltimore______]
	State			[MD][V]
	Zip Code			[21228]
Phone Number	 U.S	 Foreign
	[4104567890] ext: [230]
Fax Number (optional)	 U.S	 Foreign
	[4104567891]

Payment Preference for this Affiliation:

Method of Payment	 Check	 Direct Deposit
Are you the owner or co-owner of this account?	 Yes	¡ No
Nine-Digit Routing Number	[123456789]	[Lookup Financial Institution]
Name of Financial Institution	Bank of America
Type of Account	 Checking	¡ Savings
Account Number	[12121212121212_]

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AR Menu

Personal/Professional Information

Business Affiliation Details

1699 Summary

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Appointed Representative System

Form 1699

Employee: Jane S. Doe Today’s Date Is: Monday Jan 2, 2006

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

AR Menu

Personal/Professional Information

Business Affiliation Details

1699 Summary

1699 Summary

Personal/Professional Information:

Action	Personal	Professional
[ View/Edit ]	123-45-6789 Andrew Allan Attorney Jr. Tax Mailing Address: 123 Apple St Baltimore, MD 21207 USA	Attorney Virginia Supreme Court of Virginia

Business Affiliations:

Action	Name of Business	Notice/Payment Address	Payment Preference
[ Add Affiliation ]
[ View/Edit ]	Self Employed Sole Proprietor or Single-Member LLC/LLP	Calle Cuatro # 21 Cartagena Colombia CA-936 (123) 456-7890 Fax: 123456789012345	Check
[ View/Edit ]	Binder and Binder 11-1111111 Partner or Salaried employee	123 Frederick Rd Suite 102 Baltimore, MD 21228 (410) 456-7890 ext: 230 Fax: (410) 456-7891	Direct deposit to: Bank of America RTN:123456789 Acct:12121212121212 Checking

Applicant has signed the form SSA-1699.

Please verify data entered and click Submit.

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