Form SSA-1696 (08-2020) UF 
Discontinue Prior Editions                                                                                          Page 1 of 6 
Social Security Administration                                                                               OMB No. 0960-0527

                           Instructions for Completing Form SSA-1696
                                           Keep a copy of this form for your records
DO NOT FILE form SSA-1696 if you do not have a claim, you are not filing a claim with this form, or there is no other 
issue pending decision with us. In this document, “you” means the claimant, beneficiary, auxiliary or spouse. “Us” and “SSA” 
means the Social Security Administration.

General Information About This Form
• You have the right to appoint a qualified representative of your choice to represent you on any claim or asserted right under any 
of our programs. For more information on who can qualify to be an appointed representative, when your representative's 
appointment begins or ends, payment of fees to appointed representative(s), and other helpful information, or to locate your local 
field office, you can visit our website at www.ssa.gov/locator. Call us, toll-free, at 1-800-772-1213.  
• You and your representative(s) may use this form to start the representation. Your representative may also use this form to 
waive a fee, waive direct payment of the fee, or tell us that a third party will pay the fee.   
• You may also choose to be unrepresented. We handle your case in the same manner whether you are represented or 
unrepresented. You do not need to appoint someone who simply helps you through the process. For example, you do not need 
to appoint someone who helps you come to our office, reads to you from documents, or interprets for you if you speak another 
language. You only need to appoint someone if he or she will be acting or appearing on your behalf, or will be making decisions 
about your case for you. 
• You and your representative(s) must give us accurate information as quickly as possible. Providing misleading or false evidence 
on this form or your application, or withholding or delaying giving us evidence, could lead to possible criminal charges or 
administrative sanctions against you or your representative.

Appointing a Representative
If you are using this form to appoint a representative, you must complete Sections 1, 2, and 3. Your representative must complete 
Sections 5 and 7 of this form. Both you and your representative must complete Section 4, either of you can complete section 6. 
You or your representative must file the completed form with us, in-person at your local field office, by mail, or by fax. Review and 
complete all required sections. If you are appointing multiple representatives, use separate forms for each representative. Your 
representative or someone else can help you complete the form but you must sign and date Section 8. Your representative must 
also sign the form if he or she is a non-attorney. You or your representative must submit the completed form to us before we will 
recognize your representative. You can file it in-person at your local field office, mail it, or fax it to us. Do not file this form with your 
local State Disability Determination Services office.
Section 1 - Claimant's Information and Number Holder's Information
Complete all of the information, including your Social Security Number. If you are filing your claim on someone else's Social 
Security record, this person is the “number holder” and we need his or her information to process your claim.

Section 2 - Authorization for Disclosure
By selecting the disclosure box, you are authorizing us to give information to your representative's staff, partners, associates and 
other individuals who work for or with your representative (such as contractors and copying services). We will check the 
credentials of the individuals requesting information on behalf of your representative for authentication purposes. 

Section 3 - Principal Representative
If you appoint or have appointed multiple representatives, you must name your principal representative who will be our main point 
of contact. We will send copies of your notices to this individual and communicate directly with him or her.

Section 4 - Representative's Information
Both you and your representative must complete all of the information in this section. It is important to fill in all the boxes, including 
the Representative Identification Number (Rep ID). Ask your representative for his or her Rep ID, if you do not know it. This box 
should only be left blank if your representative does not have a Rep ID.

Section 5 - Representative's Status, Affiliations, and Certifications
Your representative must complete this section to let us know his or her status as a professional. If your representative is seeking 
a fee and is working for an employer, entity or firm, he or she must also complete the affiliation section and give us the Employer’s 
Identification Number (EIN). We will provide both your representative and the employer, entity, or firm with a copy of the form IRS 
1099-MISC showing the reported income. For more information on form 1099-MISC and employer registration, visit our website at 
www.ssa.gov/representation. Your representative should also certify the accuracy of all statements in this section.

Form SSA-1696 (08-2020) UF                                                                                          Page 2 of 6
Section 6 - Claim Type
Either you or your representative can complete this section. Check all types of claims for which you seek representation.

Section 7 - Fee Arrangement
Complete this section, if your representative is or will be asking for a fee for services performed on your claim. Generally, to 
charge a fee for services, your representative must get our approval. Your representative may waive the right to charge you a fee 
or tell us that a third party entity (business, government agency, or organization) will pay the fee. In these situations, the third party 
must pay out of its own funds the fee and any expenses, and you and any auxiliary beneficiaries (e.g., children or spouse) must 
be free of responsibility to pay any fees or expenses. If your representative is eligible for direct payment, he or she also may waive 
the right to direct payment.

Section 8 - Signatures
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.

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.  Furnishing us this 
information is voluntary.  However, failing to provide all or part of the information may prevent us from appointing a representative 
to act on your behalf.   
  
We will use the information to verify the appointment of your representative and his or her acceptance of the appointment.  We 
may also share your information for the following purposes, called routine uses:  
  
     • To a congressional office in response to an inquiry from that office made on behalf of, and at the request of, the subject 
      of the record or a third party acting on the subject’s behalf; 
  
     • To Federal, State, and local law enforcement agencies and private security contractors, as appropriate, information 
      necessary:   
  
          (a) to enable them to protect the safety of Social Security Administration (SSA) employees and customers, the 
              security of the SSA workplace, and the operation of SSA facilities; or  
          (b) to assist investigations or prosecutions with respect to activities that affect such safety and security or 
              activities that disrupt the operation of SSA facilities; and  
  
     • To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration 
      of its programs.   
  
In addition, we may share this information in accordance with the Privacy Act and other Federal laws.  For example, where 
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with 
other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent 
debts under these programs. 
  
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089, entitled Claims 
Folders Systems, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784; 60-0320, entitled Electronic 
Disability Claim File, as published in the FR on December 22, 2003, at 68 FR 71210; and 60-0325, entitled Appointed 
Representative File, as published in the FR on October 8, 2009, at 74 FR 51940.  Additional information and a full listing of all our 
SORNs are available on our website at www.ssa.gov/privacy.

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 
control number. We estimate that it will take about 30 minutes to read the instructions, gather the facts, and answer the questions. 
You may send us your comments on our estimated completion time 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; 42 U.S.C. §§ 406, 1320a-6, 1383(d)(2) and 1631;  
• 26 U.S.C. §§ 6041 and 6045(f) and 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq. 

Form SSA-1696 (08-2020) UF 
Discontinue Prior Editions                                                                                          Page 3 of 6 
Social Security Administration                                                       OMB No. 0960-0527
           Claimant's Social Security Number                      Appointed Representative's Rep ID

                    -           -

                           Claimant's Appointment of a Representative

                                           Section 1 - Claimant's Information

First Name                                          Initial Last Name

Mailing Address

City                                                State         ZIP/Postal Code Country - if outside the U.S.

Phone Number                                 Alternate Phone Number (Optional)

Country/Area Code               Phone Number        Country/Area Code                Phone Number

                               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)

     By selecting this box, I, the claimant listed in Section 1, whose signature appears in Section 8, authorize SSA to release 
     information in relation to my pending claim(s) or asserted right(s) 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.)

               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

Form SSA-1696 (08-2020) UF                                                                                           Page 4 of 6
           Claimant's Social Security Number                               Appointed Representative's Rep ID

                -          -

                  Section 4 - Representative's Information (Claimant and Representative)

Representatives who are eligible and seek direct payment of their fee must register and receive a Rep ID before the appointment. 
For more information about registration visit us on-line at www.socialsecurity.gov/ar, contact us at 1-800-772-1213  
(TTY 1-800-325-0778), or visit your local Social Security office. 

First Name                                                        Initial Last Name

Mailing Address

City                                                              State    ZIP/Postal Code Country - if outside the U.S.

Phone Number                                                      Alternate Phone Number (Optional)

Country/Area Code          Phone Number                           Country/Area Code  Phone Number

     Section 5 - Representative's Status, Affiliations, and Certifications (Representative Only)

Representative's Status Part A - Type of Representative (Representatives have a duty to keep their information current)

I am an attorney (SSA law states that an attorney is someone in good standing who has the right to practice law before a 
court of a State, Territory, District, or island possession of the United States, or before the Supreme Court or a lower 
Federal court of the United States.) 

I am a non-attorney eligible for direct payment (SSA law requires that non-attorneys meet certain criteria to qualify for direct 
payment. Refer to our website at www.ssa.gov/representation for criteria).

I am a non-attorney not eligible for direct payment.

I work for a non-profit organization (e.g. a law clinic or state legal aid)

                                 Representative's Status Part B - Disqualification

I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice law.

Yes        No

I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.

Yes        No

Form SSA-1696 (08-2020) UF                                                                                              Page 5 of 6
                Claimant's Social Security Number                              Appointed Representative's Rep ID

                     -              -

                                         Section 5 - Continued (Representative Only)

                                                       Affiliation Information
If you are representing the claimant(s) as a partner or employee of a business entity, firm or other organization you may provide 
your Employer Identification Number (EIN) here, if one exists for tax purposes. This number is not your Social Security Number 
(SSN). This is your employer’s tax identification number. (Do not complete this section if you do not qualify for direct payment.)

EIN
                -
Organization’s Name (Enter the full name of the business, entity, firm or organization with which you want to be affiliated while 
representing this claim)

Representative's Business Address (if different than mailing address)

City                                                            State                                  ZIP/Postal Code

Country - if outside the U.S.

                                           Representative's Certifications

I accept this appointment and certify the following:   
                                                                  
• I understand and agree that I will comply with SSA's laws and rules on the representation of parties, including the Rules of 
  Conduct and Standards of Responsibility for Representatives; I will not charge, collect, or retain a fee for representational 
  services that SSA has not approved or that is more than SSA approved unless a regulatory exclusion applies. 
• I understand that if I fail to comply with any of SSA's laws and rules I may be suspended or disqualified as a representative 
  before SSA. 
• I will not disclose any information to any unauthorized party without the claimant's specific written consent. 
• I am not currently suspended or prohibited, for any reason, from practicing before the Social Security Administration.  
• I am not disqualified from representing the claimant as a current or former officer or employee of the United States. 
• I accept appointment as the representative for the claimant named in Section 2 of this form in connection with the claims and 
  asserted rights described in Section 6 of this form. 
• I agreethat a copy of this signed form SSA-1696 will have the same force and effect as the original. 
• I declare under penalty of perjury that I have examined all of the information on this form and on all accompanying statements or 
  forms, including any information, attestations and certifications provided to SSA in registration, and that they are all currently true 
  and correct to the best of my knowledge. 
  
If I intend to seek direct payment of the authorized fee on this claim - 
• I have registered for and obtained a Rep ID, and my registration information is up-to-date. 
• I have provided up-to-date information on my registration concerning whether I have been suspended or prohibited from practice 
  before SSA or any other Federal program or agency, disbarred or suspended by a court or bar, and convicted of a violation 
  under Section 206 or 1631(d) of the Social Security Act.

                     I CERTIFY TO ALL OF THE ABOVE                    (Representative's Initials)

Form SSA-1696 (08-2020) UF                                                                                          Page 6 of 6
     Claimant's Social Security Number                                         Appointed Representative's Rep ID

              -                 -

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

     Claim/Appeal for Title II Disability Benefits

     Claim/Appeal for Title XVI Disability Benefits

     Concurrent Title II and Title XVI Disability Benefits

     Claim/Appeal for Retirement Benefits

     Claim/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)

Check one box below:

     I will request a fee and direct payment of this fee. Select this box if you are eligible for direct payment and want us to 
     withhold a portion of the past-due benefits to pay you the fee we may authorize. (We must authorize the fee.)

     I will request a fee but not direct payment. Select this box if you are not eligible for direct payment from the past-due 
     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.)

     I waive the right to receive a fee from the claimant, any auxiliary beneficiaries or any other individual. Select this 
     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 waive the right to a fee.

                                Section 8 - Signatures (Claimant and Representative)

Representative's Signature                                                              Date

Claimant's Signature                                                                    Date