Form SSA-1696 (12-2024) UF
Social Security Administration
Claimant's Social Security Number
*
Choose Attorney
Please Select
James Gannon
Section 1 - Claimant's Information
Full Name
*
First Name
Middle Initial
Last Name
Section 7 - Other Claimants
List below any auxiliary claimants, such as a child or spouse of the claimant or number holder, who have not appointed their own representative.
Claimant 1
Claimant 1 Social Security Number
Claimant 2
Claimant 2 Social Security Number
Claimant 3
Claimant 3 Social Security Number
Claimant 4
Claimant 4 Social Security Number
Section 8 - Signatures
(Claimant)
Claimant's Signature
Date
/
Month
/
Day
Year
Date
Submit
Should be Empty: