Form SSA-1696-U4 Appointment of Representative

What Is Form SSA-1696-U4?

Form SSA-1696-U4, Appointment of Representative is a form used for appointing a third-party representative who will act on your behalf when doing business with the Social Security Administration (SSA). The form - also known as the SSA Form 1696-U4 or the SSA Appointment of Representative - was released in March 2018. An SSA-1696-U4 fillable form is available for download and digital filing below.

Dealing with the SSA may be troublesome - especially for the individuals requesting disability benefits - and often requires a lot of paperwork. In this case, the SSA gives you an opportunity to appoint a representative who will deal with the official procedures for you. You may choose any person you want to act as your representative, including your attorney or close relative. It is very important that you appoint a qualified and reliable person because the appointed representative will have right to act for you in most Social Security cases, and the SSA will work with this person just as they would with you.

ADVERTISEMENT
Form SSA-1696-U4 (03-2018) UF
Discontinue Prior Editions
Page 1 of 9
Social Security Administration
OMB No. 0960-0527
Completing This Form to Appoint a Representative
Choosing to be Represented
How to Complete this Form
Please print or type your answers on this form. At the top of the
You can choose to have a representative help you when you
form, provide your full name and your Social Security number.
do business with Social Security. We will work with your
If your claim is based on another person's work and earnings,
representative, just as we would with you. It is important that
also provide the “wage earner's” name and Social Security
you select a qualified person because, once appointed, your
number. If you appoint more than one individual as your
representative may act for you in most Social Security matters.
representative, you may want to complete a form for each of
We give more information, and examples of what a
them.
representative may do, in the section titled “Information for
Claimants.”
Part 1 Claimant's Appointment of Representative
Privacy Act Statement
Give the name and address of the individual(s) you are
Collection and Use of Personal Information
appointing. You may appoint an attorney or any other qualified
individual to represent you. You also may appoint more than
Sections 206 and 1631(d) of the Social Security Act, as
one individual, but please refer to the “Information for
amended, allow us to collect this information. Furnishing us
Claimants” section “What your Representative(s) May Charge”
this information is voluntary. However, failing to provide all or
for more information about payment of fees. You can appoint
part of the information may prevent us from appointing a
one or more individuals in a firm, corporation, or other
representative to act on your behalf.
organization as your representative(s), but you may not appoint
a law firm, legal aid group, corporation or organization itself.
We will use the information to verify the appointment of your
Check the block(s) showing the program(s) under which you
representative and his or her acceptance of the appointment.
have a claim. You may check more than one block. Check:
We may also share your information for the following purposes,
called routine uses:
• Title II (RSDI), if your claim concerns retirement,
survivors, or disability insurance benefits.
1. To a congressional office in response to an inquiry
• Title XVI (SSI), if your claim concerns Supplemental
from that office made on behalf of, and at the
Security Income.
request of, the subject of the record or a third party
• Title XVIII (Medicare Coverage), if your claim concerns
acting on the subject’s behalf.
2. To Federal, State, and local law enforcement
entitlement to Medicare or enrollment in the
agencies and private security contractors, as
Supplementary Medical Insurance (SMI) plan.
appropriate, information necessary: (a) to enable
• Title VIII (SVB), if your claim concerns entitlement to
them to protect the safety of Social Security
Special Veterans Benefits.
Administration (SSA) employees and customers,
the security of the SSA workplace, and the
When you give your permission your representative may
operation of SSA facilities; or (b) to assist
designate an associate (e.g. a clerk), or other party or entity (e.
investigations or prosecutions with respect to
g. a copying service) to receive information from your claim file
activities that affect such safety and security or
on your representative's behalf for the duration of your claim. If
activities that disrupt the operation of SSA facilities;
you want to give your representative permission to do that,
and
check the block to authorize this release.
3. To contractors and other Federal agencies, as
necessary, for the purpose of assisting SSA in the
If you will have more than one representative, check the
efficient administration of its programs.
appropriate block and give the name of the individual you want
to be your principal representative. SSA will make contacts
In addition, we may share this information in accordance with
with, and send notices or requests for development to, only the
the Privacy Act and other Federal laws. For example, where
principal representative. The principal representative will
authorized, we may use and disclose this information in
provide copies of notices or requests to other co-
computer matching programs, in which our records are
representatives.
compared with other records to establish or verify a person’s
eligibility for Federal benefit programs and for repayment of
You must sign and date the form. Print or type your address,
incorrect or delinquent debts under these programs.
area code and telephone number.
A list of additional routine uses is available in our Privacy Act
System of Records Notices (SORNs) 60-0089, entitled Claims
If you are appointing a representative to replace a
Folders Systems; 60-0320, entitled Electronic Disability Claim
representative that you discharged or who withdrew his or her
File; and 60-0325, entitled Appointed Representative File.
representation, you must notify us in writing that the prior
Additional information and a full listing of all our SORNs are
appointment has ended.
available on our website at
www.socialsecurity.gov/foia/bluebook.
Form SSA-1696-U4 (03-2018) UF
Discontinue Prior Editions
Page 1 of 9
Social Security Administration
OMB No. 0960-0527
Completing This Form to Appoint a Representative
Choosing to be Represented
How to Complete this Form
Please print or type your answers on this form. At the top of the
You can choose to have a representative help you when you
form, provide your full name and your Social Security number.
do business with Social Security. We will work with your
If your claim is based on another person's work and earnings,
representative, just as we would with you. It is important that
also provide the “wage earner's” name and Social Security
you select a qualified person because, once appointed, your
number. If you appoint more than one individual as your
representative may act for you in most Social Security matters.
representative, you may want to complete a form for each of
We give more information, and examples of what a
them.
representative may do, in the section titled “Information for
Claimants.”
Part 1 Claimant's Appointment of Representative
Privacy Act Statement
Give the name and address of the individual(s) you are
Collection and Use of Personal Information
appointing. You may appoint an attorney or any other qualified
individual to represent you. You also may appoint more than
Sections 206 and 1631(d) of the Social Security Act, as
one individual, but please refer to the “Information for
amended, allow us to collect this information. Furnishing us
Claimants” section “What your Representative(s) May Charge”
this information is voluntary. However, failing to provide all or
for more information about payment of fees. You can appoint
part of the information may prevent us from appointing a
one or more individuals in a firm, corporation, or other
representative to act on your behalf.
organization as your representative(s), but you may not appoint
a law firm, legal aid group, corporation or organization itself.
We will use the information to verify the appointment of your
Check the block(s) showing the program(s) under which you
representative and his or her acceptance of the appointment.
have a claim. You may check more than one block. Check:
We may also share your information for the following purposes,
called routine uses:
• Title II (RSDI), if your claim concerns retirement,
survivors, or disability insurance benefits.
1. To a congressional office in response to an inquiry
• Title XVI (SSI), if your claim concerns Supplemental
from that office made on behalf of, and at the
Security Income.
request of, the subject of the record or a third party
• Title XVIII (Medicare Coverage), if your claim concerns
acting on the subject’s behalf.
2. To Federal, State, and local law enforcement
entitlement to Medicare or enrollment in the
agencies and private security contractors, as
Supplementary Medical Insurance (SMI) plan.
appropriate, information necessary: (a) to enable
• Title VIII (SVB), if your claim concerns entitlement to
them to protect the safety of Social Security
Special Veterans Benefits.
Administration (SSA) employees and customers,
the security of the SSA workplace, and the
When you give your permission your representative may
operation of SSA facilities; or (b) to assist
designate an associate (e.g. a clerk), or other party or entity (e.
investigations or prosecutions with respect to
g. a copying service) to receive information from your claim file
activities that affect such safety and security or
on your representative's behalf for the duration of your claim. If
activities that disrupt the operation of SSA facilities;
you want to give your representative permission to do that,
and
check the block to authorize this release.
3. To contractors and other Federal agencies, as
necessary, for the purpose of assisting SSA in the
If you will have more than one representative, check the
efficient administration of its programs.
appropriate block and give the name of the individual you want
to be your principal representative. SSA will make contacts
In addition, we may share this information in accordance with
with, and send notices or requests for development to, only the
the Privacy Act and other Federal laws. For example, where
principal representative. The principal representative will
authorized, we may use and disclose this information in
provide copies of notices or requests to other co-
computer matching programs, in which our records are
representatives.
compared with other records to establish or verify a person’s
eligibility for Federal benefit programs and for repayment of
You must sign and date the form. Print or type your address,
incorrect or delinquent debts under these programs.
area code and telephone number.
A list of additional routine uses is available in our Privacy Act
System of Records Notices (SORNs) 60-0089, entitled Claims
If you are appointing a representative to replace a
Folders Systems; 60-0320, entitled Electronic Disability Claim
representative that you discharged or who withdrew his or her
File; and 60-0325, entitled Appointed Representative File.
representation, you must notify us in writing that the prior
Additional information and a full listing of all our SORNs are
appointment has ended.
available on our website at
www.socialsecurity.gov/foia/bluebook.
Form SSA-1696-U4 (03-2018) UF
Page 2 of 9
Part 2 Representative's Acceptance of Appointment
Each individual you appoint in Part I should also complete Part 2.
If the individual is not an attorney, he or she must give his or her
name, state that he or she accepts the appointment, and sign the
form.
Part 3 Fee Arrangement
To help in processing benefits and fee payments timely you and
your representative should complete this section. Your
representative should check a box, sign and date the form. Your
representative may choose to receive payment, waive direct
payment, or waive payment of the fee altogether. If you and your
representative change your arrangement before we decide your
claim, you can provide a new or amended form so that we can
update our records. If you appoint a second representative or co-
counsel who also will not charge a fee, he or she should also
complete this part or provide a new form, or if not using the form,
give us a separate, written waiver statement. If your
representative is not eligible for direct payment, or is an attorney
or an eligible non-attorney who waives direct payment, you will
be responsible for paying any fee we authorize.
Under certain circumstances, we do not have to authorize the
fee. These circumstances include where a Court has awarded a
fee based on your representative's actions as a legal guardian or
court-appointed representative, or where a business (such as an
insurance company), other organization or government agency
will pay your representative's fee and you and your beneficiaries
have no liability to pay any fees or expenses.
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 and Budget control number. We
estimate that it will take about 10 minutes to read the
instructions, gather the facts, and answer the questions. SEND
THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. The office is listed under U. S.
Government agencies in your telephone directory or you
may call Social Security at 1-800-772-1213 (TTY
1-800-325-0778). You may send comments on 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.
References
• 18 U.S.C. §§ 203, 205, and 207; and 42 U.S. C. §§ 406 (a),
1320a-6, and 1383(d)(2)
• 20 CFR §§ 404.1700 et. seq., 408.1101, and 416.1500 et. seq.
• Social Security Rulings 83-27 and 82-39
• 26 U.S.C. §§ 6041 and 6045(f)
Form SSA-1696-U4 (03-2018) UF
Page 3 of 9
Information for Representatives
Fees for Representation
Fee Agreement Process
An attorney or other individual who wants to charge or collect a
If you and the claimant have a written fee agreement, one of
fee for providing services in connection with a claim before the
you must give it to us before we decide the claim(s). We
Social Security Administration (SSA) must generally obtain our
usually will approve the agreement if:
prior authorization of the fee for representation. The only
exceptions are if:
• you both signed it;
• certain requirements are met and a third-party entity, such as a
• the fee you agreed on is no more than 25 percent of past-due
business, an insurance carrier, a for profit, or nonprofit
benefits, or $6,000 (or a higher amount we set and announce
organization or a government agency will pay the fee and any
in the Federal Register), whichever is less;
expenses from its own funds and the claimant and auxiliary
beneficiaries incur no liability, directly or indirectly, for the cost
• we approve the claim(s); and
(s); or
• the claim results in past-due benefits.
• a Federal court awarded a fee based on the representative's
activities as the claimant's legal guardian or court-appointed
We will send you a copy of the notice we send the claimant
representative;
telling him or her the amount of the fee you can charge based
on the agreement.
• a Federal court awarded a fee for representational services
provided before the court. In those cases, neither the Federal
If we do not approve the fee agreement, we will tell you in
court nor SSA can authorize a fee for the other.
writing. We also will tell you and the claimant that you must file
Obtaining Authorization of a Fee
a fee petition if you wish to charge and collect a fee.
To charge a fee for services, you must use one of two mutually
After we tell you the amount of the fee you can charge, you or
exclusive fee authorization processes. You must file either a fee
the claimant may ask us in writing to review the authorized fee.
petition or a fee agreement with us. In either case, you cannot
If we approved a fee agreement, the person who decided the
charge more than the fee amount we authorize.
claim(s) also may ask us to lower the amount. Someone who
did not decide the amount of the fee the first time will review
Fee Petition Process
and finally decide the amount of the fee.
You may file a fee petition after you complete your services to
the claimant. This written request must describe in detail the
Collecting a Fee
amount of time you spent on each service provided and the
You may accept money for your fee in advance, as long as you
amount of the fee you are requesting. In order to directly pay you
hold it in a trust or escrow account. The claimant never owes
under a fee petition, you must either file a fee petition or notify us
you more than the fee we authorize, except for:
within 60 days after we decide the claim of your intent to file a
fee petition.
• any fee a Federal court allows for your services before it; and
You must give the claimant a copy of the fee petition and each
• out-of-pocket expenses you incur or expect to incur, for
attachment. The claimant may disagree with the information
example, the cost of getting evidence. Our authorization is
shown by contacting a Social Security office within 20 days of
not needed for such expenses.
receiving his or her copy of the fee petition. We will consider the
reasonable value of the services provided, and send you notice
If you are not an attorney and you are ineligible to receive
of the amount of the fee you can charge.
direct payment, you must collect the authorized fee from the
claimant. If you are interested in becoming eligible to receive
direct payment, you can find more information about this on our
"Representing Social Security Claimants" website:
http://www.ssa.gov/representation/.
Form SSA-1696-U4 (03-2018) UF
Page 4 of 9
If you are an attorney or a non-attorney whom SSA has found
References
eligible to receive direct payment and you register with SSA, as
• 18 U.S.C. §§ 203, 205, and 207; and 42 U.S.C. §§ 406 (a),
described below, we usually withhold 25 percent of any past-due
1320a-6, and 1383(d)(2)
benefits that result from a favorably decided retirement,
• 20 CFR §§ 404.1700 et. seq., 408.1101, and 416.1500 et.
survivors, disability insurance, or supplemental security income
seq.
claim. Once we authorize a fee, we pay you all or part of the fee
• Social Security Rulings 83-27 and 82-39
from the funds withheld. We will also charge you the assessment
• 26 U.S.C. §§ 6041 and 6045(f)
required by section 206(d) and 1631(d)(2)(C) of the Social
Security Act. You cannot charge or collect this expense from the
claimant. You will need to collect from the claimant:
• the rest of the fee he or she owes, if the amount of the
authorized fee is more than the amount of money we withheld
and paid you for the claimant, plus any amount you held for the
claimant in a trust or escrow account.
• all of the fee he or she owes, if we did not withhold past-due
benefits, (for example, because there are no past-due benefits;
you waived direct payment or did not register for direct
payment; the claimant discharged you or you withdrew from
representing before we issued a favorable decision); or we
withheld past-due benefits, but you did not ask us to authorize
a fee or tell us that you planned to ask for a fee within 60 days
after the date of the notice of award and we released the
withheld amount to the claimant.
Registering for Direct Fee Payment
If you are eligible and want to receive direct payment, you must
register with us before we effectuate a favorable decision on the
claim. To register, you must submit a Form SSA-1699
(Registration of Individuals and Staff for Appointed
Representative Services) once and a Form SSA-1695
(Identifying Information for Possible Direct Payment of
Authorized Fees) with each appointment. We will use the
information you provide on these forms to issue you a Form
1099-MISC if we pay you aggregate fees of $600 or more in a
calendar year. The Internal Revenue Code requires that we do
this. For information on the registration process, see our
"Representing Social Security Claimants" website
http://www.ssa.gov/representation/.
Conflict of Interest and Penalties
If you commit improper acts, you can be suspended or
disqualified from representing anyone before SSA. You also
can face criminal prosecution. Improper acts include:
• If you are or were an officer or employee of the United States,
providing services as a representative in certain claims against
and other matters affecting the Federal government.
• Knowingly and willingly furnishing false information.
• Charging or collecting an unauthorized fee, or charging or
collecting too much for services provided in any claim,
including services before a court that made a
favorable decision.
Form SSA-1696-U4 (03-2018) UF
Page 5 of 9
Discontinue Prior Editions
OMB No. 0960-0527
Please read the instructions before completing the form.
Social Security Administration
Name (Claimant) (Print or Type)
Social Security Number
Wage Earner (If Different)
Social Security Number
Part 1 - Claimant's Appointment of Representation
I appoint this individual,
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)
Title VIII (SVB)
This individual may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get
information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I authorize the Social Security Administration to release information about my pending claim(s) or asserted right(s) to
designated associates who perform administrative duties (e.g. clerks), partners, and/or parties under contractual
arrangements (e.g. copying services) for or with my representative.
I appoint, or I now have, more than one representative. My principal representative is:
Name of Principal Representative
Address
Signature (Claimant)
Telephone Number (with Area Code)
Fax Number (with Area Code)
Date
Part 2 - Representative's Acceptance of Appointment
I,
, hereby accept the above appointment. I certify that I have not
been suspended or prohibited from practice before the Social Security Administration; that I am not disqualified from representing
the claimant as a current or former officer or employee of the United States; and that I will not charge or collect any fee for the
representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to
on the reverse side of the representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will
notify the Social Security Administration. (Completion of Part 3 satisfies this requirement.)
Check one:
I am an attorney
I am a non-attorney eligible for direct payment under SSA law.
I am a non-attorney not eligible for direct payment.
I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice as
an attorney.
Yes
No
I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.
Yes
No
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.
Address
Signature (Representative)
Telephone Number (with Area Code)
Fax Number (with Area Code)
Date
Part 3 - Fee Arrangement
(Select an option, sign and date this section.)
I am charging a fee and requesting direct payment of the fee from withheld past-due benefits. (SSA must authorize the fee
unless a regulatory exception applies.)
I am charging a fee but waiving direct payment of the fee from withheld past-due benefits - I do not qualify for or do not
request direct payment. (SSA must authorize the fee unless a regulatory exception applies.)
I am waiving fees and expenses from the claimant and any auxiliary beneficiaries - By checking this block I certify that
my fee will be paid by a third-party entity or government agency, and that the claimant and any auxiliary beneficiaries are free
of all liability, directly or indirectly, in whole or in part, to pay any fee or expenses to me or anyone as a result of their claim(s)
or asserted right(s). (SSA does not need to authorize the fee if a third-party entity or a government agency will pay from its
funds the fee and any expenses for this appointment. Do not check this block if a third-party individual will pay the fee.)
I am waiving fees from any source - I am waiving my right to charge and collect any fee, under sections 206 and 1631 (d)(2)
of the Social Security Act. I release my client and any auxiliary beneficiaries from any obligations, contractual or otherwise,
which may be owed to me for services provided in connection with their claim(s) or asserted right(s).
Signature (Representative)
Date
File Copy

Download Form SSA-1696-U4 Appointment of Representative

923 times
Rate
4.6(4.6 / 5) 55 votes
ADVERTISEMENT

Form SSA-1696-U4 Instructions

According to the SSA rules, you are not allowed to choose a company as your representative (e.g. law firm), but you can appoint several individuals working in the company. The appointed representative will be able to:

  • retrieve information from your file maintained by the SSA;
  • submit to the SSA pieces of evidence for your claims;
  • appoint associates who will perform administrative duties (with your permission only);
  • request reconsideration of the SSA decisions, hearings, or make an appeal;
  • accompany you to all meetings and interviews with the SSA;
  • help you and your witnesses with the preparation to hearing or interview;
  • receive copies of all decisions the SSA makes on your claims.

The SSA will continue working with your representative unless you provide them with a written notification of withdrawal, or the representative notifies them about a cessation of performing their duties. The SSA will not work with an individual who is suspended or disqualified. The SSA will inform you in case your representative is suspended. Your representative may ask for a fee. To charge you a fee, your representative must receive an authorization from the SSA.

How Do I Fill out Form SSA-1696-U4?

The SSA Appointment of Representative Form consists of three parts. The first part is completed by a claimant. Parts 2 and 3 are filled out by the representative. You can use one Form SSA-1696 to appoint one representative. If you choose to appoint multiple representatives, submit a separate form for each of them.

Fill out the Form SSA-1696-U4 as follows:

  1. Provide your full name and Social Security number (SSN);
  2. If you claim benefits based on work and earnings of some other person, specify the name and SSN of this person in the field "Wage Earner";
  3. Indicate the name and the address of the individual you appoint as your representative;
  4. Check the applicable blocks to specify the programs under which you have a claim; you are allowed to check more than one block;
  5. Choose "Title II (RSDI)" for claims concerning disability insurance, retirement, or survivors benefits;
  6. Choose "Title XVI (SSI)" for claims concerning Supplemental Security Income;
  7. Choose "Title XVIII (Medicare Coverage)" for claims concerning your enrollment to the Supplementary Medical Insurance plan or Medicare;
  8. Choose "Title VIII (SVB)" for claims concerning Special Veterans Benefits.
  9. Check the appropriate box if you authorize your representative to designate an associate who will receive information from your SSA claim file on the behalf of your representative;
  10. If you appoint more than one representative, check the appropriate box and specify the name of the person you appoint as your principal representative;
  11. Sign and date the form;
  12. Provide your mailing address, telephone, and fax number.

The representative you appoint should complete Part 2. If the appointed individual is not an attorney, it is required to provide the name, confirm the acceptance of the appointment, and sign the form. If your representative requests a fee, it is necessary to check the appropriate box in Part 3, sign and date the form in this section.

What Is the SSA-1696-U4 OHO Copy?

The form is completed in four copies. The first one is filed with the SSA, the second copy is for the claimant, the third is for the appointed representative, and the third is for the Office of Hearing Operations (OHO). The OHO is the Social Security hearing office where administrative law judges hold appeals hearings. You need to fill out this copy of the form, as the representative you appoint can request to appeal SSA decisions at a local OHO, provide the office with evidence to support your claim, and accompany you to the hearing.

Where to Send SSA-1696-U4?

Mail or fax your SSA-1696-U4 Form to the local Social Security office. Specify the mailing address and fax number of your Social Security Office on the SSA official website or by calling the toll-free Customer Service number provided at the second page of the form. Moreover, you can find a full list of the offices in your telephone directory under U.S. Government agencies. If you appoint multiple representatives, make sure that each of them has completed Part 2 of the appropriate form.

Page of 9