Ssa 1696 U4 Form

Form SSA-1696-U4 03-2018 UF Discontinue Prior Editions Social Security Administration Page 1 of 9 OMB No. 0960-0527 Completing This Form to Appoint a Representative Choosing to be Represented How to Complete this Form You can choose to have a representative help you when you do business with Social Security. If you and your claim you can provide a new or amended form so that we can update our records. If you appoint a second representative or cocounsel 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. 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. seq. Please read the instructions before completing the form. Name Claimant Print or Type Wage Earner If Different I appoint this individual to act as my representative in connection with my claim s or asserted right s under 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. G. a copying service to receive information from your claim file on your representative s behalf for the duration of your claim. If you want to give your representative permission to do that check the block to authorize this release. If you will have more than one representative check the appropriate block and give the name of the individual you want to be your principal representative. SSA will make contacts with and send notices or requests for development to only the principal representative. SSA will make contacts with and send notices or requests for development to only the principal representative. The principal representative will provide copies of notices or requests to other corepresentatives. You must sign and date the form. Print or type your address area code and telephone number. If you are appointing a representative to replace a representation you must notify us in writing that the prior appointment has ended. Part 2 Representative s Acceptance of Appointment Each individual you appoint in Part I should also complete Part 2. The principal representative will provide copies of notices or requests to other corepresentatives. You must sign and date the form. Print or type your address area code and telephone number. If you are appointing a representative to replace a representation you must notify us in writing that the prior appointment has ended. 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 payment or waive payment of the fee altogether. If your 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. 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.