Form SSA-1691 Eligible Non-Attorney Representative

Form SSA-1691 (XX-20XX)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0699

Application to Participate in the Eligible For
Direct Payment Non-Attorney Representative Program
In this document, “you” means the non-attorney applicant. “Us,” “we” and “SSA” means the Social Security Administration.

General information about this form
The purpose of this form is to collect your information, which we will review and determine whether you qualify to take the
examination, participate in the program, and act as an eligible for direct payment non-attorney (EDPNA). You must complete this
application carefully and provide all supporting documentation as required. If you have any questions, visit our Representing
Social Security Claimants website at http://www.ssa.gov/representation/.
Attorneys who have fees paid directly from their clients' past-due benefits pursuant to section 206 of the Social Security Act
(the Act) are not required to take the examination. Attorneys who are suspended or disbarred by a State or Federal court or
disqualified from appearing before a Federal agency or program are not eligible to receive direct payment and should not submit
an application.

Application fee
The Commissioner may assess applicants a reasonable, non-refundable fee to cover the costs of administering the prerequisites
process. We only accept checks from a U.S. financial institution and money orders. Visit http://www.ssa.gov/representation to find
out where to pay this fee and other guidelines about this application fee.
If you fail the examination, or we find you ineligible to take the examination because you do not meet the educational
requirement, you may reapply in any future application period, but must pay the full fee again. If we find you ineligible to take the
exam because you failed the background check, you cannot reapply in any future application period.

Examination
You are required to pass an examination testing your knowledge of the relevant provisions of the Act and the most recent
changes in Agency regulations and court decisions affecting Titles II and XVI of the Act. For more information about the details of
the examination, visit http://www.ssa.gov/representation/.

Instructions for completing this form
This form is available in fillable PDF form during the application period at http://www.ssa.gov/representation/. If you are using a
printed copy, type or print legibly using only a blue or black ink pen. Complete all sections. If you need to provide additional
information, attach an supplementary page.

Section 1 – Applicant’s Information
Complete all the information, including your name, Social Security Number, date of birth and contact information.

Section 2 – Educational or Equivalent Professional Work Experience Information
Complete only the applicable information.
You must possess either a bachelor’s degree from an accredited U.S. postsecondary institution or a high school diploma or
general equivalency diploma (GED) plus four years of relevant professional experience that we determine to be equivalent to a
bachelor’s degree. You must meet these requirements prior to the date the application period begins. Relevant professional
experience means training or work through which you demonstrate familiarity with medical reports and an ability to describe and
assess mental or physical limitations or both. Such experience may be in the fields of: teaching, counseling or guidance, social
work, personnel management, public employment service, nursing or other health care services. Professional work involving
evaluating or adjudicating claims for benefits under Title II or Title XVI of the Act also qualifies as relevant professional
experience.
You must send proof of your educational qualifications after you pass the examination. Failure to do so precludes you from
establishing your eligibility to receive direct payment of fees. Visit http://www.ssa.gov/representation/ for types of acceptable
proof.

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Form SSA-1691 (XX-20XX)

Section 3 – Disqualification
Respond to all statements and provide relevant information as it applies.

Section 4 – Examination Location
We administer the examination(s) on a single day each year at designated locations across the country. We may cancel the
examination(s) scheduled for any designated location if enrollment is insufficient. In that event, we will notify you at least 20 days
prior to the examination date, so you can make appropriate travel arrangements to an alternate examination location. See
http://www.ssa.gov/representation/ for a list of examination locations.
You must select a first and second choice for your preferred examination location when applicable. If you submit your application
timely but do not select a second choice, we will return your applications as incomplete. We will send detailed information
concerning the specific location of the examination site by mail to those applicants we deem eligible to sit for the examination.

Section 5 – Signatures
Read and initial the first two statements before signing the form in ink below the perjury statement.

Section 6 – Criminal Background Check
Complete all fields. We use this information to ensure your fitness to practice before us. Visit http://www.ssa.gov/representation/
to review the requirements or our criminal background check.

Privacy Act Statement
Collection and Use of Personal Information
Section 206(e) of the Social Security Act, as amended, allows us to collect this information. Furnishing us this information is
voluntary. However, failing to provide all or part of the information may prevent us from determining your eligibility for direct
payment.
We will use the information to determine your eligibility for direct payment. We may also share your information for the following
purposes, called routine uses:
• To contractors and other Federal agencies, as necessary, to assist us in efficiently administering our programs. We will
disclose information under this routine use only in situations in which we may enter into a contractual or similar
agreement with a third party to assist in accomplishing an agency function relating to this system of records; and
• To student volunteers, persons working under a personal services contract, and others who are not technically Federal
employees, when they are performing work for us, as authorized by law, and they need access to information in our
records in order to perform their assigned duties.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0325, entitled Appointed
Representative File, as published in the Federal Register (FR) on October 8, 2009, at 74 FR 51940. Additional information, and a
full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.

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 Budget control number.
We estimate that it will take 45 minutes to read the instructions, gather the facts, and answer the questions. Send only comments
relating to 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.

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Form SSA-1691 (XX-20XX)

Application to Participate in the Eligible For
Direct Payment Non-Attorney Representative Program
Section 1 - Applicant's Information
First Name

Full Middle Name

Last Name

Suffix

Other Names Used (with reason)

SSN

Date of Birth (mm/dd/yyyy)

Citizenship status
U.S. Citizen

Naturalized Citizen

Mailing Address

City

State

Preferred Email Address

Alternate Email Address

Phone Number
Area Code

Zip Code

Alternate Phone Number
Phone Number

Area Code

Phone Number

Work Phone Number
Area Code

Phone Number

Section 2 - Educational or Equivalent Professional Work Experience Information
U.S. postsecondary degree received
Doctorate Degree

Graduate Degree

Name of U.S. College or University

Attended from Date (mm/yyyy)

Bachelor's Degree
City

Attended to Date (mm/yyyy)

State

Degree granted
Yes

High School or GED certificate received (not required with postsecondary degree)
High School Diploma
City

GED Certificate
State

No

Date awarded (mm/yyyy)

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Form SSA-1691 (XX-20XX)

Section 2 - Educational or Equivalent Professional Work Experience Information - Continued
Relevant professional experience (not required with postsecondary degree)
SSA-related professional experience

Other professional experience

Position/Title

From Date to Date (mm/yyyy)

Position Description

Name of Employer

Address of Employer

City

State

Zip Code

Employer Phone Number

Name of Supervisor

Area Code

Phone Number

Additional relevant professional experience (not required with postsecondary degree)
SSA-related professional experience

Other professional experience

Position/Title

From Date to Date (mm/yyyy)

Position Description

Name of Employer

Address of Employer

City

Name of Supervisor

State

Zip Code

Employer Phone Number
Area Code

Phone Number

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Form SSA-1691 (XX-20XX)

Section 3 - Disqualification
I am now or have been disqualified, sanctioned or suspended from participating in any Federal program
or appearing before the SSA or any other Federal Agency.

Yes

No

If Yes, provide Name of Program or Agency

Address of Program or Agency

City

State

Zip Code

Details of Disqualification, Sanction or Suspension

Date of Disqualification, Sanction or Suspension (mm/dd/yyyy)

Date of Reinstatement (mm/dd/yyyy)

I am now or have been disqualified, sanctioned or suspended from participating in any Federal program
or appearing before the SSA or any other Federal Agency.

Yes

No

If Yes, provide Name of Program or Agency

Address of Program or Agency

City

State

Zip Code

Details of Disqualification, Sanction or Suspension

Date of Disqualification, Sanction or Suspension (mm/dd/yyyy)

Date of Reinstatement (mm/dd/yyyy)

I have fraudulently used or misused any
Social Security Benefits

Yes

No

I have a judgment or lien assessed
against me by a civil court for malpractice
and/or fraud

Yes

No

I have a record for felony conviction

Yes

No

I have violated Social Security program
rules (e.g., rules regarding disclosure of
evidence or representative payee rules)

Yes

No

Yes

No

I have previously applied for the Social Security Administration Eligible for Direct payment Non-attorney
Representative examination. (If you were previously denied because of a failed background check, you
may not reapply again.)

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Form SSA-1691 (XX-20XX)

Section 4 - Examination Location
If offered multiple examination locations, you must indicate your first two choices. You cannot select the same location twice.
City

State

City

State

First Choice

Second Choice
Describe any special accommodation(s) you will need at the examination location. Please note that you must provide supporting
documentation from a professional qualified to determine your condition along with your application to the address indicated on
the Representing Social Security Claimants Website at http://www.ssa.gov/representation/.

I certify that I understand that I must provide written documentation to support my request for special accommodations along with
this application.

Initials

Section 5 - Acknowledgments and Signature
If I cannot substantiate the statements made in my application or it is determined that the
information I entered is incorrect, I understand that I may be determined ineligible to sit for the
examination or to receive direct payment of fees.

Initials

Initials
The application fee is generally non-refundable.

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 statement about a material fact in this information, or causes someone else to do so, commits a crime and
may be subject to a fine or imprisonment.
Signature (in ink)

Date (mm/dd/yyyy)

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Form SSA-1691 (XX-20XX)

Section 6 - Criminal Background Information
I authorize SSA to conduct a criminal background check so SSA 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 SSA any criminal history information pertaining to me that may be in the agency’s files. I authorize SSA, and
any of its agents, to disclose orally and in writing the results of this criminal background check to the business entity that manages
the information for managing direct payment eligibility for non-attorney representatives.
I understand that the results of the criminal background check may be used by SSA to determine my eligibility to sit for the
examination and receive direct payment, 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
sit for the examination or to receive direct payment, I understand that SSA will provide me a copy of the report on the criminal
background check submitted by SSA 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.
First Name

Middle Name

Last Name

Date of Birth (mm/dd/yyyy)

Place of Birth

SSN

Sex

Race (optional)

List of addresses for the last five years
Current address

City, State, Zip Code

From date (mm/dd/yyyy) to present

Current address

City, State, Zip Code

From date (mm/dd/yyyy) to present

Current address

City, State, Zip Code

From date (mm/dd/yyyy) to present

Current address

City, State, Zip Code

From date (mm/dd/yyyy) to present

Current address

City, State, Zip Code

From date (mm/dd/yyyy) to present

Signature (in ink)

Date (mm/dd/yyyy)

Daytime Phone Number

Area Code

Phone Number