Form SSA-1693 Fee Agreement for Representation before the Social Secur

Form SSA-1693 (12-2024)
Discontinue Prior Editions Social Security Administration

INSTRUCTIONS FOR COMPLETING FORM SSA-1693
Keep a copy of this form for your records.

File Form SSA-1693 only if you or your representative are submitting or have submitted a notice of
appointment on a pending claim, matter, or issue with us.
In this document, “you” means the claimant, beneficiary, auxiliary beneficiary, or spouse.
Requesting a fee for representational services
Your representative may ask for a fee for the services they provided in your claim. Not all
representatives ask for a fee, and some only charge a fee if they win your case. To charge you a fee
for services related to your claim(s), your representative generally must get our approval. Your
representative can get our approval by submitting a fee agreement (you may use this form) or a fee
petition. You and your representative choose which of these two processes to use. Under the fee
agreement process the amount your representative can ask for is limited by the Social Security Act.
Under the fee petition process your representative can ask for a higher fee. For more information on
fees, fee processes and our rules, visit our website at www.ssa.gov/representation.
Registration
Beginning September 30, 2024, all representatives must register with us using Form SSA-1699
Representative Registration prior to being appointed. They will receive a Representative ID (Rep ID)
once the registration is processed.
For more information on representative registration visit us on-line at www.socialsecurity.gov/ar,
contact us at 1- 800-772-1213 (TTY 1-800-325-0778), or contact your local Social Security office.
When to file a fee agreement
You or your representative must file your fee agreement before we issue a favorable determination or
decision in your case. If you or your representative submit the fee agreement after our determination or
decision, we will disapprove your fee agreement.
What you have to pay
Under the terms of a fee agreement, you will pay an amount up to 25 percent of your total past-due
benefits or an amount set by us, whichever is less. You must pay the fee we authorize. Your
dependents or your auxiliary beneficiaries will also pay a fee unless they have their own
representation. In addition to the fee we authorize, you may also have to pay:

• Fees authorized by a Federal court for services your representative provided during
the court proceedings, and
• Any “out-of-pocket” expenses your representative may incur (e.g., costs for making
copies of a doctor's or hospital's records).
Note: These fees and expenses do not require our authorization.
Two-tiered fee agreements
Although representatives may only use either a fee agreement or a fee petition in each case (they are
mutually exclusive), you and your representative can limit the effect of a fee agreement to a certain
appeal level. Representatives can file a fee petition if your case is appealed beyond the specified
administrative level. You and your representative can choose this option on the attached form.
Trust and escrow accounts
Your representative may accept money from you before we authorize a fee as long as they hold it in a
trust or escrow account according to our rules and policy. If you choose to enter into the trust or escrow
agreement with your representative, you may willingly deposit the money in the trust or escrow account
and tell us on this form. Only complete this field if your representative is using an escrow or trust
account.

Page 1 of 5
OMB No. 0960-0810

Third-party payments
We collect information on payments your representative may receive from a third party for services your representative provided
to you during the administrative proceedings. These fees may be in lieu of your fee payment, or may be in addition to your
payment. We may consider these payments during our authorization process to determine if we need to authorize these fees
under our rules. All statutory and regulatory rules continue to apply in situations involving third-party payments.
Withholding of funds and direct payment to your representative
If your representative is eligible under our rules to receive an authorized fee directly from us, we usually withhold 25 percent of
your TII/TXVI past-due (retroactive) benefits for direct payment of that fee. For more information on when you must pay your
representative the authorized fee directly, visit our Public Policy page at https://secure.ssa.gov/apps10/poms.nsf/lnx/0203920006.
Signatures
You and your representative must sign and date this form. If you appoint multiple representatives, all representatives who
provide representational services on your claim and who do not waive a fee for those services must sign on a single fee
agreement for the fee agreement to be approved. They may use the last page for this purpose.

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, which we will use to
authorize fees for services rendered to the claimant named on the form. Providing the information is voluntary, but not providing
all or part of the information may affect the amount of fees authorized for services rendered before SSA. As law permits, we may
use and share the information you submit, including with other Federal agencies, contractors, and others, as outlined in the routine
uses within System of Records Notices (SORN) 60-0003, 60-0089, and 60-0325, available at www.ssa.gov/privacy. The
information you submit may also be used in computer matching programs to establish or verify eligibility for Federal benefit
programs and to recoup debts under these programs.
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 (OMB) control number. We estimate that it will take about 7 minutes to read the instructions, gather the facts, and
answer the questions. You may send us comments on our time estimate to: SSA, 6401 Security Boulevard, 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,
• 26 U.S.C. §§ 6041 and 6045(f),
• 42 U.S.C. §§ 406(a), 1320a-6, and 1383(d)2),
• 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq.
Social Security Administration

OMB No. 0960-0810

Fee Agreement for Representation Before the Social Security Administration
General Information
You can use this form to file an agreement between you and your representative(s) to seek our authorization of the fee for
services your representative(s) will provide before us. Section 206 of the Social Security Act limits the fee we authorize under a
fee agreement to 25 percent of your past-due (retroactive) benefits or a maximum dollar amount we set, whichever is less. Your
dependents or auxiliary beneficiaries who do not have their own representation will also be liable for a fee. This form does not
limit you and your representative(s) from agreeing to any additional terms unrelated to the fee. Requesting, receiving, or keeping
a fee in excess of the legal limit or in excess of what we authorize is unlawful and may lead to sanctions for your
representative(s).

Representative's Information
Representative's Rep ID

First Name

Initial

Last Name

Mailing Address

City

State

Phone Number
Country/Area Code

Phone Number
Claimant's Information

Claimant's Social Security Number

-

-

First Name

Initial

Last Name

Mailing Address

City

State

Phone Number
Country/Area Code

Alternate Phone Number (Optional)
Phone Number

Country/Area Code

Phone Number

Claimant's Social Security Number

-

Representative's Rep ID

-

Standard Fee Agreement
If SSA favorably decides my claim(s) and the determination or decision results in past-due (retroactive) benefits, I agree to pay
my representative(s) a fee that does not exceed the lesser of 25 percent of my past-due benefits or the maximum dollar amount
allowed under the Social Security Act Section 206(a)(2), or such higher amount set by the Commissioner of Social Security based
on the maximum dollar amount in effect as of the date of my favorable determination or decision. The current maximum fee
amount is available on the Public Policy page on our website at https://secure.ssa.gov/apps10/poms.nsf/lnx/0203920006.

Choose One:
I agree to pay the maximum fee as stated in the preceding paragraph. By selecting this box, I acknowledge my
representative has informed me of the current maximum dollar amount that I may have to pay and also that SSA may increase
the maximum dollar amount before the date of my favorable determination or decision.
I agree to pay less than the maximum: I agree to pay the lesser of $ _____________or _____________ %.
Read and acknowledge the following:
I understand that, subject to the maximum dollar amount in effect, SSA also may authorize fees to my representative based on
past-due benefits awarded to my unrepresented spouse or any unrepresented auxiliary beneficiary.
I understand that I, my eligible spouse, any affected auxiliary beneficiary, my representative or the decision maker
have the right to protest the fee authorized under this fee agreement, in writing, within 15 days from the authorization.
I understand that my representative may still request a fee even if my case does not result in past-due benefits, or the
determination or decision is not favorable. If the fee agreement cannot be approved because there are no past-due benefits or
for other reasons, my representative may file a fee petition to request that SSA authorize a fee. I also understand that if there are
no past-due benefits withheld, if not enough past-due benefits are withheld, or if my representative is not eligible for direct
payment by SSA, I will be responsible to pay the authorized fee to my representative(s) directly. SSA does not authorize out-ofpocket costs, and expenses which I am responsible for paying directly to my representative.

Claimant's Initials

Two-Tiered Fee Agreement (Optional)
Only complete this section if you and your representative(s) have chosen to limit the effect of this fee agreement to a certain
administrative level.

If my claim(s) proceeds beyond the
level of review and results in a favorable determination
or decision due to that appeal, the fee agreement is void and my representative(s) may seek a higher fee by filing a fee petition.
SSA must authorize this fee.

Claimant's Social Security Number

-

-

Representative Rep ID

Escrow/Trust Accounts or Third-party Payments (Optional)
Only complete this section if your representative(s) will use an escrow or trust account, or someone other than you or your
spouse, dependents or auxiliary beneficiaries or another individual has paid or will pay your representative fee.
With my consent my representative(s) has/have or will establish an escrow/trust account in the amount of $
My representative will receive a fee from another party (e.g., state, county, private entity) for $
and I will have no financial responsibility to pay any fee, unless SSA authorizes the total fee.
Only representatives who have been properly appointed can be authorized to receive a fee under the fee agreement process. The
claimant and any representative not waiving a fee are each required to sign this fee agreement.

Claimant and Representative Signatures
By signing this form, I affirm all of the information provided above and acknowledge that I have been informed of the maximum dollar
amount that I may have to pay and also that SSA may increase this maximum dollar amount before the date of my favorable
determination or decision. However, if this fee agreement reflects that the parties have agreed to a fee that is less than the maximum
dollar amount, the agreed upon lower amount will remain applicable regardless of any changes to the maximum dollar amount.

Claimant's Signature

Date

By signing this form, I affirm all of the information provided above and acknowledge that I have informed the claimant of the maximum
dollar amount that they may have to pay and also that SSA may increase this maximum dollar amount before the date of the
favorable determination or decision. I will inform the claimant of any increase in the maximum dollar amount that occurs before the
date of the favorable determination or decision. However, if this fee agreement reflects that the parties have agreed to a fee that is
less than the maximum dollar amount, the agreed upon lower amount will remain applicable regardless of any changes to the
maximum dollar amount.

Representative's Signature

Date

Claimant's Social Security Number

-

Representative's Rep ID

-

Additional Signatures
This page is optional - Use only if multiple appointed representatives want to sign the same fee agreement
By signing this form, I affirm all of the information provided above and acknowledge that I have informed the claimant of the maximum
dollar amount that they may have to pay and also that SSA may increase this maximum dollar amount before the date of the favorable
determination or decision. I will inform the claimant of any increase in the maximum dollar amount that occurs before the date of the
favorable determination or decision. However, if this fee agreement reflects that the parties have agreed to a fee that is less than the
maximum dollar amount, the agreed upon lower amount will remain applicable regardless of any changes to the maximum dollar
amount.
Representative's Rep ID

Representative's Name, Signature, and Date