Form SSA-1696-SUP2 Representative's Withdrawal of Acceptance of an Appointm

Form SSA-1696-SUP2 (XX-20XX)
Social Security Administration

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OMB No. 0960-0527

Instructions for Completing Form SSA-1696-SUP2
Keep a copy of this form for your records
In this document, “you” means the representative. “Us” and “SSA” means the Social Security Administration.
General Information About This Form
This form is optional. Complete it only when applicable.
Withdrawal of a Representative
If you wish to withdraw your acceptance of the appointment, you must sign and date the withdrawal and file it with us either inperson at your local field office, mail it, or fax it to us. You should also tell the claimant. Your withdrawal will take effect on the date
we receive the signed document. Under our recent revisions to our Rules of Conduct and Standards of Responsibility for
Appointed Representatives, effective August 1, 2018, representatives should withdraw representation only at a time and in a
manner that does not disrupt the processing or adjudication of a claim, and allows the claimant adequate time to find new
representation, if desired. Once a hearing has been scheduled, a representative should not withdraw his or her representation
unless “extraordinary circumstances” exist (83 CFR 30849). We will make determinations on whether a representative has
withdrawn in a disruptive manner on a case-by-case basis. Some examples of “extraordinary circumstances” include a serious
illness of the representative, a death or serious illness in the representative’s immediate family, or failure to locate the claimant
who is being represented in the particular action, despite active and diligent attempts to contact the claimant. While we will not
prevent a representative from withdrawing, if we determine the representative has withdrawn in a disruptive manner, we will refer
the representative to the Office of General Counsel to consider pursuing sanctions. However, if another representative replaces
the representative who is seeking to withdraw and there is no impact on the hearing process, we will not consider the withdrawal
disruptive.

DRAFT

Privacy Act Statement - Collection and Use of Personal Information
Sections 206 and 1631(d) of the Social Security Act, as amended, allow 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 ending your appointment as
representative.
We will use the information to withdraw your acceptance of appointment as representative for the claimant named on the form. We
may also share your information for the following purposes, called routine uses:
• To a congressional office in response to an inquiry from that office made on behalf of, and at the request of, the subject
of the record or a third party acting on the subject’s behalf;
• To a Federal, State, and local law enforcement agencies and private security contractors, as appropriate,
information necessary:
(a) to enable them to protect the safety of Social Security Administration (SSA) employees and customers, the
security of the SSA workplace, and the operation of SSA facilities; or
(b) to assist investigations or prosecutions with respect to activities that affect such safety and security or
activities that disrupt the operation of SSA facilities; and
• To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration
of its programs.
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 Notices (SORN) 60-0089, entitled Claims
Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784; 60-0320, entitled Electronic Disability
Claim File, as published in the FR on December 22, 2003, at 68 FR 71210; and 60-0325, entitled Appointed Representative File,
as published in the FR on October 8, 2009, at 74 FR 51940. Additional information and a full listing of all our SORNs are available
on our website at www.ssa.gov/privacy.
Paperwork Reduction Act Statement
This information collection meets the clearance 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 about 30 minutes to read the instructions, gather the facts, and answer
the questions. You may send us your comments on our estimated completion time to SSA, 6401 Security Blvd., Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
References
• 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq.

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Form SSA-1696-SUP2 (XX-20XX)

Representative's Withdrawal of Acceptance of an Appointment
You, the representative, can stop working for the claimant. Complete, sign, and date the section below and submit it to one of our
offices. Do not forget to enter the claimant’s Social Security Number and your Rep ID.

Representative's Information
Representative's Rep ID

Representative's First Name

Initial Last Name

Representative's Address

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City

State

ZIP/Postal Code

State

ZIP/Postal Code

Claimant's Information
Claimant's Social Security Number

-

-

Claimant's First Name

Initial Last Name

Claimant's Address

City

I am withdrawing from this appointment.
I was seeking a fee, but I hereby waive my fee
Representative's Signature

I am seeking a fee and will file a fee petition
Date