Appointment of Representative - SSA-1696 and SSA-1696-App

Appointment of Representative

Documents and Forms

Document Name Document Type
Form SSA-1696 Appointment of Representative - SSA-1696 and SSA-1696-App Form and Instruction
SSA-1696-APP Screens.pdf www.ssa.gov Other-SSA-1696-APP - Submittable PDF
SSA-1696-APP Screens.pdf www.ssa.gov Other-SSA-1696-APP - Submittable PDF
SSA-1696 Appointment of Representative SSA-1696 - Current Version.pdf www.ssa.gov Form and Instruction
SSA-1696 Appointment of Representative SSA-1696 (Revised).pdf www.ssa.gov Form and Instruction
SSA-1696 - Current Version.pdf Current SSA-1696 IC Document

Information Collection (IC) Details

IC Title:	Appointment of Representative - SSA-1696 and SSA-1696-App	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.1507 20 CFR 410.684 20 CFR 404.1720 20 CFR 404.1707 20 CFR 414.1725

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-1696	Appointment of Representative	SSA-1696 (Revised).pdf	www.ssa.gov	Yes	No	Fillable Printable
Other-SSA-1696-APP - Submittable PDF Screens			SSA-1696-APP Screens.pdf	www.ssa.gov	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,100,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,100,000	300,000	800,000
Annual IC Time Burden (Hours)	220,000	60,000	160,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-1696	SSA-1696 - Current Version.pdf	05/19/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.