Continuing Education

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https://secure.cps.ca.gov/tlc/ssa/accounts/dpstatus.asp

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OMB 0960-0699

SSA Non-Attorney Representative
Direct Payment Demonstration Project
Name:
Work Phone:
Home Phone:
Email:
Address:
City/State/Zip:
In order to receive Direct Pay, the address you
provide on this screen must match the address that
is reflected on your 1696. If the address you provide
on this screen is not the same as the address you
provide to SSA on your 1696, you must provide your
1696 address here.

Update your contact information
Update your 1696 information
Update Your Continuing Education Information
Update your insurance information
Your Annual Affirmations were
completed 8/24/2007 10:16:11 AM
Review or Update Your Annual Affirmations
Please read ALL questions on the Affirmations
Worksheet CAREFULLY before answering.

SSA Non-Attorney Representative Representative Direct Payment Project

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https://secure.cps.ca.gov/tlc/ssa/ce/ssacesummary.asp

Continuing Education
In order to maintain your eligibility to participate in the demonstration project, you must meet certain continuing education
(CE) requirements. Click here for more information about the CE requirements. You can report your CE courses to us via this
website. If you have any questions about the information required on this website, or prefer to mail your CE information to
us, click here for CPS contact information.
Ethics/
Professional Conduct Entitlement/Eligibility
Reporting Period (7/1/2005 - 12/31/2006)
Show claimed courses
Add A Claim

1.50

15.75

Ethics/
Professional Conduct Entitlement/Eligibility
Reporting Period (1/1/2007 - 12/31/2008)
Show claimed courses
Add A Claim

2.50

23.50

Total
(approved credit)
17.25

Total
(approved credit)
26.00

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10/15/2009 11:55 AM

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https://secure.cps.ca.gov/tlc/ssa/ce/ssacourseform.asp

Instructions

Continuing Education - Course Information
Approvals
Course Status:

Internal Notes:
(2000 max)

Notes To
Participant:
(2000 max)

Status By:

For which Continuing Education (CE) period is this course?

The credit hours being reported are for the current CE period.
The credit hours being reported are for a prior CE period.
Please enter the Title and Description of the course:
Title:
Description:

(Maximum
2000 Characters)

Completion Date:
Please enter the actual number of credit hours for the course. If you were the
instructor, the system will calculate your approved hours.
Number of Hours:
Were you the instructor
for this course?
Did you receive a certificate?

Please indicate the course category:
Ethics/Professional Conduct
Entitlement to, or eligibility for, benefits under titles II and XVI
of the Act;
Please indicate the type of Organization providing the course:
Accredited College/University
State Bar Association
Organization Accredited by a State Bar
Professional Organization that (in whole or in part) specializes in
representing claimants before governmental agencies
Governmental Agency

Name of College or Institution:

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Name of Instructor or
Contact Person:
Phone Number of Instructor or Contact
Person:

Privacy Act Statement
The information requested on this form 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 receive direct payment of fees (from a claimant's
past-due benefits) for your representation services. Information
requested on this form is voluntary. However, if you do not provide
the required information, a decision based on the evidence in your
records can result in a determination that you are ineligible for direct
payment of fees. While the information you furnish on this form 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:

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 minutes to read the instructions, gather the facts,
and answer the questions. SEND THE COMPLETED CONTINUING
INFORMATION SUBMISSION FORM 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:

Replace text with "6401 Security Blvd.,
Update Information

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OMB 0960-0737

0699

10/15/2009 11:55 AM