Form SSA-1696

Form SSA-1696 (08-2020) UF Discontinue Prior Editions Social Security Administration

You must sign and date this section. If your representative is not an attorney, he or she also must sign and date this section. We also encourage attorneys to sign this section to confirm that they will abide by our rules.

Claimant's Social Security Number

Appointed Representative's Rep ID

First Name

Initial

Last Name

Mailing Address

City

State

ZIP/Postal Code

Country - if outside the U.S.

Phone Number

Format: (000) 000-0000.

Alternate Phone Number (Optional)

Format: (000) 000-0000.

Number Holder's Information (Complete when applicable)

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 (Claimant Only)

information in relation to my pending claims or asserted rights 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

By selecting this box, I, the claimant listed in Section 1, whose signature appears in Section 8, authorize SSA to release

Section 3 - Principal Representative (Claimant only – Complete when applicable)

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

Section 6 - Claim Type (Claimant or Representative)

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

Claimant's Social Security Number

Appointed Representative's Rep ID

amended, specifically for the issues identified below: Check all that apply

Claim/Appeal for Title II Disability BenefitsClaim/Appeal for Title XVI Disability BenefitsConcurrent Title II and Title XVI Disability BenefitsClaim/Appeal for Retirement BenefitsClaim/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 (Representative Only)

withhold a portion of the past-due benefits to pay you the fee we may authorize. (We must authorize the fee

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

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 will request a fee and direct payment of this fee. Select this box if you are eligible for direct payment and want us toI will request a fee but not direct payment. Select this box if you are not eligible for direct payment from the past-dueI waive the right to receive a fee from the claimant, any auxiliary beneficiaries or any other individual. Select thisI waive the right to a fee.

Section 8 - Signatures (Claimant and Representative)

Representative's Signature

Date

Claimant's Signature

Date

Form SSA-1696

Claimant's Appointment of a Representative

First Name

Representative's Certifications