SSA-1696 Appointment of Representative

Form SSA-1696-APP (05-2023)
UF Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0527

Instructions for Completing Form SSA-1696
Follow the link we send you after you submit the form to print and/or save a copy of this form for your records
YOU DO NOT HAVE TO SIGN THIS FORM – Use and sign this form to appoint an individual to act on your behalf in your claim
pending with us. If you do not agree with any information on this form, do not sign it. Refusing to sign the form will not affect how we
process and decide your claim.
You may only file this electronic version of Form SSA-1696 if you have a claim or other issue pending with us. In this document,
“you” means the claimant, beneficiary, auxiliary, or spouse. “Us” and “SSA” means the Social Security Administration.
If you suspect Social Security Fraud - If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the Inspector
General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).
General Information About This Form
• You may appoint a qualified representative of your choice to represent you on any claim or asserted right under any of our
programs. For more information on who can qualify to be an appointed representative, when your representative's
appointment begins or ends, payment of fees to appointed representative(s), and other helpful information, you can visit our
website at www.ssa.gov/representation, or call us, toll-free, at 1-800-772-1213. To find other helpful information or the
address and telephone number for your local Social Security field office, you can visit www.ssa.gov/locator.
• You may use this electronic version of Form SSA-1696 to appoint a representative. However, we do not require you to use
this electronic version; you can still use the paper version to tell us about your appointment. After you read, complete, and
electronically sign the form, you must click “Click to Sign” to send us this form, or your appointment will not reach us. If we
successfully process your appointment, we will send you a notice to tell you. You do not need to submit a paper form if you
submit this electronic version.
• You may also choose to be unrepresented. We handle your case in the same manner whether you are represented or
unrepresented. You do not need to appoint someone who simply helps you through the process. For example, you do not need to
appoint someone who helps you call us, reads to you from documents, or interprets for you if you speak another language. You
only need to appoint someone if he or she will be acting or appearing on your behalf, or will be making decisions about your case
for you. If you choose to be unrepresented (or do not want to appoint the individual identified on this electronic form), do not
complete or submit this form.
• You and your representative(s) must give us accurate information as quickly as possible. Providing misleading or false evidence
on this form or your application, or withholding or delaying giving us evidence, could lead to possible criminal charges or
administrative sanctions against you or your representative.
Appointing a Representative
Before completing your sections of this electronic form, please review the sections that you can view that were completed by the
representative. If you agree with all of the information already entered, complete the highlighted sections, electronically sign and date
the form in Section 8, and submit it to us by clicking “Click to Sign.” After you submit the form successfully, you will receive an email
from adobesign@adobesign.com with a link that will take you to a copy of the completed form that you can keep for your records. If
you are appointing multiple representatives, you must use a separate form for each representative.
Section 1 - Claimant's Information and Number Holder's Information
Your representative will complete your information, including your Social Security number. If you are filing your action on someone
else's Social Security record, this person is the “number holder” and we need his or her information to process your claim.
Section 2 - Authorization for Disclosure
By selecting yes, you are authorizing us to give information to your representative's staff, partners, associates, and other
individuals who work for or with your representative (such as contractors and copying services) about you and your pending case.
We will check the credentials of the individuals requesting information on behalf of your representative for authentication purposes.
Section 3 - Principal Representative
If you appoint or have appointed multiple representatives, you must name your principal representative who will be our main point of
contact. We will send copies of your notices to this individual and communicate directly with him or her. Your representative will
complete this section.
Section 4 - Representative's Information
Your representative will complete this section and submit this form by clicking “Click to Sign.” It is important that he or she fill in all the
boxes in this section, including the Representative Identification Number (Rep ID) if he or she has one.

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Section 5 - Representative's Status, Affiliations, and Certifications
Your representative will complete this section to let us know his or her status as a professional. If your representative is seeking a
fee and is working for an employer, entity, or firm, he or she must also complete the affiliation section and give us the Employer’s
Identification Number (EIN). We will provide both your representative and the employer, entity, or firm information of the reported
income. For more information about your representative’s reported income and employer registration, visit our website at
www.ssa.gov/representation. Your representative must certify the accuracy of all statements in this section.
Section 6 - Claim Type
Your representative will complete this section and will check the boxes for the types of claims you appoint this person to represent
you.
Section 7 - Fee Arrangement
Your representative will complete this section. Generally, to charge a fee for services, your representative must get our approval.
Your representative may waive the right to charge you a fee or tell us that a third party entity (business, government agency, or
organization) will pay the fee. In these situations, the third party must pay out of its own funds the fee and any expenses, and you
and any auxiliary beneficiaries (e.g., children or spouse) must be free of responsibility to pay any fees or expenses. If your
representative is eligible for direct payment, he or she also may waive the right to direct payment.
Section 8 - Signatures
You must electronically sign and date this section and send the completed form to us by clicking the “Click to Sign” button.
Remember, by signing this form you are appointing the named individual as your representative and authorizing us to disclose to
him or her any information relevant to your claim(s) as if he or she were you. If you select the box in section 2, we may also disclose
the same information to your appointed representative’s associates.
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 appointing a representative to act on your
behalf.
We will use the information to verify the appointment of your representative and his or her acceptance of the appointment. 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 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 October 31, 2019, at 84 FR 58422; 60-0320, entitled Electronic
Disability Claim File, as published in the FR on June 4, 2020, at 85 FR 34477; 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, is
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
• 18 U.S.C. §§ 203, 205, and 207; 42 U.S.C. §§ 406, 1320a-6, 1383(d)(2) and 1631;
• 26 U.S.C. §§ 6041 and 6045(f) and 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq.

Form SSA-1696-APP (05-2023) UF
Discontinue Prior Editions Social
Security Administration

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OMB No. 0960-0527

Claimant's Social Security Number

Appointed Representative's Rep ID

Claimant's Appointment of a Representative
Section 1 - Claimant's Information
First Name

Initial Last Name

Mailing Address

City

State

Phone Number

ZIP/Postal Code Country - if outside the U.S.

Alternate Phone Number (Optional)

Number Holder's Information
My claim is based on another person’s work or earnings (e.g., spouse or parent). This person’s information is different from mine.
Number Holder's Social Security Number

First Name

Initial Last Name

Section 2 - Disclosure
By selecting yes in this box, I, the claimant listed in Section 1, whose signature appears in Section 8, authorize SSA to release
information in relation to my pending claim(s) or asserted right(s) to designated associates who perform administrative duties (e.g.,
clerks, assistants), partners, or parties under contractual arrangements for or with my representative. (The appointed representative’s
partners, associates, delegates and designees must be prepared to provide information in order to be authenticated.)
Yes

No

Section 3 - Principal Representative
I have appointed before, or appoint now, more than one representative. I ask SSA to make contacts or send notices to this
individual. My principal representative is:
Name

Form SSA-1696-APP (05-2023) UF

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Claimant's Social Security Number

Appointed Representative's Rep ID

Section 4 - Representative's Information
Representatives who are eligible and seek direct payment of their fee must register and receive a Rep ID before the appointment.
For more information about registration visit us on-line at www.socialsecurity.gov/ar, contact us at 1-800-772-1213
(TTY 1-800-325-0778), or visit your local Social Security office.
First Name

Initial Last Name

Mailing Address

City

State

Phone Number

ZIP/Postal Code Country - if outside the U.S.

Alternate Phone Number (Optional)

Section 5 - Representative's Status, Affiliations, and Certifications
Representative's Status Part A - Type of Representative (Representatives have a duty to keep their information current)
I am an attorney (SSA law states that an attorney is someone in good standing who has the right 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.)
I am a non-attorney eligible for direct payment (SSA law requires that non-attorneys meet certain criteria to qualify for direct
payment. Refer to our website at www.ssa.gov/representation for criteria).
I am a non-attorney not eligible for direct payment.

I work for a non-profit organization (e.g. a law clinic or state legal aid)

Representative's Status Part B - Disqualification
I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice law.
Yes

No

I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.
Yes

No

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Claimant's Social Security Number

Appointed Representative's Rep ID

Section 5 - Continued
Affiliation Information
If you are representing the claimant(s) as a partner or employee of a business entity, firm or other organization you may provide
your Employer Identification Number (EIN) here, if one exists for tax purposes. This number is not your Social Security Number
(SSN). This is your employer’s tax identification number. (Do not complete this section if you do not qualify for direct payment.)
EIN
Organization’s Name (Enter the full name of the business, entity, firm or organization with which you want to be affiliated while
representing this claim)
Representative's Business Address (if different than mailing address)

City

State

ZIP/Postal Code

Country - if outside the U.S.

Representative's Certifications
I accept this appointment and certify the following:
• I understand and agree that I will comply with SSA's laws and rules on the representation of parties, including the Rules of
Conduct and Standards of Responsibility for Representatives; I will not charge, collect, or retain a fee for representational
services that SSA has not approved or that is more than SSA approved unless a regulatory exclusion applies.
• I understand that if I fail to comply with any of SSA's laws and rules I may be suspended or disqualified as a representative
before SSA.
• I will not disclose any information to any unauthorized party without the claimant's specific written consent.
• I am not currently suspended or prohibited, for any reason, from practicing before the Social Security Administration.
• I am not disqualified from representing the claimant as a current or former officer or employee of the United States.
• I accept appointment as the representative for the claimant named in Section 2 of this form in connection with the claims and
asserted rights described in Section 6 of this form.
• I agree that a copy of this signed form SSA-1696 will have the same force and effect as the original.
• I declare under penalty of perjury that I have examined all of the information on this form and on all accompanying statements or
forms, including any information, attestations and certifications provided to SSA in registration, and that they are all currently true
and correct to the best of my knowledge.
If I intend to seek direct payment of the authorized fee on this claim • I have registered for and obtained a Rep ID, and my registration information is up-to-date.
• I have provided up-to-date information on my registration concerning whether I have been suspended or prohibited from practice
before SSA or any other Federal program or agency, disbarred or suspended by a court or bar, and convicted of a violation
under Section 206 or 1631(d) of the Social Security Act.

I CERTIFY TO ALL OF THE ABOVE

(Representative's Initials)

Form SSA-1696-APP (05-2023) UF

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Claimant's Social Security Number

Appointed Representative's Rep ID

Section 6 - Claim Type
I appoint the individual named in Section 4 to act as my representative in connection with my claim(s) or asserted right(s) under
Title II (RSDI), Title XVI (SSI), Title XVIII (Medicare Coverage), and Title VIII (SVB) of the Social Security Act, as presently
amended, specifically for the issues identified below: (Select YES for all that apply)
Yes

No
Claim/Appeal for Title II Disability Benefits
Claim/Appeal for Title XVI Disability Benefits
Concurrent Title II and Title XVI Disability Benefits
Claim/Appeal for Retirement Benefits
Claim/Appeal for Title XVIII (Medicare), VIII (Special Veteran’s Benefits)
Continuing Disability Review (CDR)
Post-Entitlement Issue (a new issue you raise after eligibility for other benefits)

(E.g., benefit amount, month of entitlement, representative payee, suspension, termination, overpayment)

Section 7 - Fee Arrangement
Check one box below:
I will request a fee and direct payment of this fee. Select this box if you are eligible for direct payment and want us to
withhold a portion of the past-due benefits to pay you the fee we may authorize. (We must authorize the fee.)
I will request a fee but not direct payment. Select this box if you are not eligible for direct payment from the past-due
benefits, or if you do not want direct payment. You must collect any fee we may authorize on your own. (We must
authorize the fee.)
I waive the right to receive a fee from the claimant, any auxiliary beneficiaries or any other individual. Select this
box if you certify that an entity, or a Federal, state, county, or city government agency will pay the fee and any expenses
from its funds. The claimant, auxiliary beneficiaries, or other individuals must not be liable for the fee, directly or indirectly,
in whole or in part, or any expenses. (We do not need to authorize the fee if all regulatory conditions apply.)
I waive the right to a fee.

Section 8 - Signatures
Representative's Signature

Date

Claimant's Signature

Date

You will need to electronically sign the document to complete your form. This form must be signed by the Appointed Representative
and the Claimant to be processed.