Annual Affirmations Worksheet

Form Approved OMB No. 0960-0699

Expires XX/XX/XX

Social Security Administration Non-Attorney Representative Direct Fee Payment Demonstration Project ANNUAL AFFIRMATIONS WORKSHEET
In order to maintain demonstration project eligibility, you must continue to meet all demonstration project prerequisites, including passing a criminal background check to ensure that you are fit to practice before the Commissioner. To ensure that you continue to meet these prerequisites, you must annually reaffirm your answers to the following questions from your demonstration project application:
1. Have you been admitted to practice law before a court of a State, Territory, District, or island possession of the United States, or before the Supreme Court or a lower Federal Court of the United States since the date you filed your application to participate in the demonstration project?				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 since the date you filed your application to participate in the demonstration project?				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 since the date you filed your application to participate in the demonstration project?				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:
5.  Have you had a judgment or lien assessed against you by a civil court for malpractice and/or fraud since the date you filed your application to participate in the demonstration project?				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 since the date you filed your application to participate in the demonstration project?				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 since the date you filed your application to participate in the demonstration project?				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 been convicted of a felony since the date you filed your application to participate in the demonstration project?				Yes		No
	Signature				Date

Privacy Act Statement
The information requested on this worksheet is authorized by section 303 of the Social Security Protection Act of 2004 (Public Law 108-203). The information provided will be used to further document your continued eligibility to participate in the demonstration project authorized by section 303 and your eligibility to receive direct payment of fees (from a claimant's past-due benefits) for your representation services. Information requested on this worksheet is voluntary. However, if you do not provide the required information, a decision based on the evidence in your file can result in a determination that you are ineligible for direct payment of fees. While the information you furnish on this worksheet would almost never be used for any purpose other than making a determination about your continued eligibility for direct payment of fees, such information may be disclosed by the Social Security Administration (SSA) for the following purposes (1) to assist SSA in determining your eligibility for direct payment of fees (2) to facilitate statistical research and audit activities necessary to assure the integrity and improvement of the demonstration project administered by SSA, and (3) to comply with laws and regulations requiring the exchange of information between SSA and another agency.
Please initial indicating that you have read and understand the Privacy Act Statement:
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take 10 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED WORKSHEET TO CPS HUMAN RESOURCE SERVICES. You may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address.
Please initial indicating that you have read and understand the Paperwork Reduction Act Statement: