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Form SSA-1696-U4 Appointment of Representative
What Is Form SSA-1696?
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 U.S. Social Security Administration (SSA). The form was released on March 1, 2018 . An SSA-1696-U4 fillable form is available for download and digital filing below.
Alternate Names:
- Form SSA-1696;
- SSA Form 1696-U4;
- SSA Appointment of Representative Form.
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 the right to act for you in most Social Security cases, and the SSA will work with this person just as they would with you.
Form SSA-1696-U4 Instructions
According to the SSA's 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 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 a single representative. If you choose to appoint multiple representatives, submit a separate form for each of them. Fill out Form SSA-1696-U4 as follows:
- Provide your full name and Social Security Number (SSN).
- 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."
- Indicate the name and the address of the individual you appoint as your representative.
- Check the applicable blocks to specify the programs under which you have a claim; you are allowed to check more than one block.
- Choose "Title II (RSDI)" for claims concerning disability insurance, retirement, or survivors benefits.
- Choose "Title XVI (SSI)" for claims concerning Supplemental Security Income.
- Choose "Title XVIII (Medicare Coverage)" for claims concerning your enrollment to the Supplementary Medical Insurance plan or Medicare.
- Choose "Title VIII (SVB)" for claims concerning Special Veterans Benefits.
- 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.
- If you appoint more than one representative, check the appropriate box and specify the name of the person you appoint as your principal representative.
- Sign and date the form. 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 on 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.
Download Form SSA-1696-U4 Appointment of Representative
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