Social Security Administration Form Approved

Please read the back of the last copy before you complete this form. OMB No. 0960-0527
Name (Claimant) (Print or Type) Social Security Number

Wage Earner (If Different) Social Security Number

Part I APPOINTMENT OF REPRESENTATIVE

I appoint this person, ,
(Name and Address)

to act as my representative in connection with my claim(s) or asserted right(s) under:

Title II Title XVI Title IV FMSHA Title XVIII

Title VIII
(RSDI) (SSI) (Black Lung) (Medicare Coverage)
(SVB)

This person 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).

I am appointing, or I now have, more than one representative. My main representative

is .
(Name of Principal Representative)

Signature (Claimant) Address

Telephone Number (with Area Code) Date

Part II ACCEPTANCE OF APPOINTMENT

I, , hereby accept the above appointment. I certify that I
have not been suspended or prohibited from practice before the Social Security Administration; that I am
not disqualified from representing the claimant as a current or former officer or employee of the United
States; and that I will not charge or collect any fee for the representation, even if a third party will pay
the fee, unless it has been approved in accordance with the laws and rules referred to on the reverse side
of the representative's copy of this form. If I decide not to charge or collect a fee for the representation,
I will notify the Social Security Administration. (Completion of Part III satisfies this requirement.)

I am an attorney. I am not an attorney. (Check one.)

Signature (Representative) Address

Telephone Number (with Area Code) Fax Number (with Area Code) Date

Part III (Optional) WAIVER OF FEE

I waive my right to charge and collect a fee under sections 206 and 1631(d)(2) of the Social Security
Act. I release my client (the claimant) from any obligations, contractual or otherwise, which may be
owed to me for services I have provided in connection with my client's claim(s) or asserted right(s).
Signature (Representative) Date

Part IV (Optional) ATTORNEY'S WAIVER OF DIRECT PAYMENT

I waive only my right to direct payment of a fee from the withheld past-due retirement, survivors,
disability insurance or black lung benefits of my client (the claimant). I do not waive my right to request
fee approval and to collect a fee directly from my client or a third party.
Signature (Attorney Representative) Date

Form SSA-1696-U4 (4-2002) EF (4-2002) (See Important Information on Reverse) FILE COPY
Destroy Prior Editions
 INFORMATION FOR CLAIMANTS

What A Representative May Do What Your Representative(s) May Charge,

continued
We will work directly with your appointed representative o Filing A Fee Agreement
unless he or she asks us to work directly with you. Your If you and your representative have a written fee
representative may: agreement, one of you must give it to us before we decide
your claim(s). We usually will approve the agreement if
o get information from your claim(s) file; you both signed it; the fee you agreed on is no more than
o give us evidence or information to support your claim; 25 percent of past-due benefits, or $5,300 (or a higher
o come with you, or for you, to any interview, amount we set and announce in the Federal Register),
conference, or hearing you have with us; whichever is less; we approve your claim(s); and your
o request a reconsideration, hearing, or Appeals Council claim results in past-due benefits. We will tell you in
review; and writing the amount of the fee your representative can
o help you and your witnesses prepare for a hearing and charge based on the agreement.
question any witnesses.
If we do not approve the fee agreement, we will tell you
Also, your representative will receive a copy of the and your representative in writing. Then your
decision(s) we make on your claim(s). We will rely on your representative must file a fee petition to charge and collect
representative to tell you about the status of your claim(s), a fee.
but you still may call or visit us for information.
After we tell you the amount of the fee your representative
can charge, you or your representative can ask us to look at it
You and your representative(s) are responsible for giving
again if either or both of you disagree with the amount. (If we
Social Security accurate information. It is wrong to
approved a fee agreement, the person who decided your
knowingly and willingly furnish false information. Doing so
claim(s) also may ask us to lower the amount.) Someone who
may result in criminal prosecution.
did not decide the amount of the fee the first time will review
and finally decide the amount of the fee.
We usually continue to work with your representative until
(1) you tell us that he or she no longer represents you; or
(2) your representative tells us that he or she is withdrawing How Much You Pay
or indicates that his or her services have ended (for You never owe more than the fee we approve, except for:
example, by filing a fee petition or not pursuing an appeal).
We do not continue to work with someone who is suspended o any fee a Federal court allows for your
or disqualified from representing claimants. representative's services before it; and
o out-of-pocket expenses your representative incurs or
expects to incur, for example, the cost of getting your
What Your Representative(s) May Charge doctor's or hospital records. Our approval is not
Each representative you appoint can ask for a fee. To charge needed for such expenses.
you a fee for services, your representative must get our
Your representative may accept money in advance as long as
approval. (Even when someone else will pay the fee for you,
he or she holds it in a trust or escrow account. If an attorney
for example, an insurance company, your representative
represents you and your retirement, survivors, disability
usually must get our approval.) One way is to file a fee
insurance, or black lung claim results in past-due benefits, we
petition. The other way is to file a fee agreement with us. In
usually withhold 25 percent of your past-due benefits to pay
either case, your representative cannot charge you more than
toward the fee for you.
the fee amount we approve. If he or she does, promptly
report this to your Social Security office.
You must pay your representative directly:
o Filing A Fee Petition
o the rest of the fee you owe
Your representative may ask for approval of a fee by
- if the amount of the fee is more than any amount(s)
giving us a fee petition when his or her work on your
your representative held for you in a trust or escrow
claim(s) is complete. This written request describes in
account and we withheld and paid your attorney for
detail the amount of time he or she spent on each service
you.
provided you. The request also gives the amount of the
fee the representative wants to charge for these services. o all of the fee you owe
Your representative must give you a copy of the fee - if we did not withhold past-due benefits, for
petition and each attachment. If you disagree with the example, when your representative is not an
information shown in the fee petition, contact your attorney or the benefits are supplemental security
Social Security office. Please do this within 20 days of income; or
receiving your copy of the petition.
- if we withheld, but later paid you the money
We will review the petition and consider the reasonable because your attorney did not either ask for our
value of the services provided. Then we will tell you in approval until after 60 days of the date of your
writing the amount of the fee we approve. notice of award or tell us on time that he or she
planned to ask for a fee.
Form SSA-1696-U4 (4-2002) EF (4-2002)
Social Security Administration Form Approved
Please read the back of the last copy before you complete this form. OMB No. 0960-0527
Name (Claimant) (Print or Type) Social Security Number

Wage Earner (If Different) Social Security Number

Part I APPOINTMENT OF REPRESENTATIVE

I appoint this person, ,
(Name and Address)

to act as my representative in connection with my claim(s) or asserted right(s) under:

Title II Title XVI Title IV FMSHA Title XVIII Title VIII

(RSDI) (SSI) (Black Lung) (Medicare Coverage) (SVB)

This person 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).

I am appointing, or I now have, more than one representative. My main representative

is .
(Name of Principal Representative)

Signature (Claimant) Address

Telephone Number (with Area Code) Date

Part II ACCEPTANCE OF APPOINTMENT

I, , hereby accept the above appointment. I certify that I
have not been suspended or prohibited from practice before the Social Security Administration; that I am
not disqualified from representing the claimant as a current or former officer or employee of the United
States; and that I will not charge or collect any fee for the representation, even if a third party will pay
the fee, unless it has been approved in accordance with the laws and rules referred to on the reverse side
of the representative's copy of this form. If I decide not to charge or collect a fee for the representation,
I will notify the Social Security Administration. (Completion of Part III satisfies this requirement.)

I am an attorney. I am not an attorney. (Check one.)

Signature (Representative) Address

Telephone Number (with Area Code) Fax Number (with Area Code) Date

Part III (Optional) WAIVER OF FEE

I waive my right to charge and collect a fee under sections 206 and 1631(d)(2) of the Social Security
Act. I release my client (the claimant) from any obligations, contractual or otherwise, which may be
owed to me for services I have provided in connection with my client's claim(s) or asserted right(s).
Signature (Representative) Date

Part IV (Optional) ATTORNEY'S WAIVER OF DIRECT PAYMENT

I waive only my right to direct payment of a fee from the withheld past-due retirement, survivors,
disability insurance or black lung benefits of my client (the claimant). I do not waive my right to request
fee approval and to collect a fee directly from my client or a third party.
Signature (Attorney Representative) Date

Form SSA-1696-U4 (4-2002) EF (4-2002) (See Important Information on Reverse) CLAIMANT'S COPY
Destroy Prior Editions
 INFORMATION FOR CLAIMANTS

What A Representative May Do What Your Representative(s) May Charge,

continued
We will work directly with your appointed representative o Filing A Fee Agreement
unless he or she asks us to work directly with you. Your If you and your representative have a written fee
representative may: agreement, one of you must give it to us before we decide
your claim(s). We usually will approve the agreement if
o get information from your claim(s) file; you both signed it; the fee you agreed on is no more than
o give us evidence or information to support your claim; 25 percent of past-due benefits, or $5,300 (or a higher
o come with you, or for you, to any interview, amount we set and announce in the Federal Register),
conference, or hearing you have with us; whichever is less; we approve your claim(s); and your
o request a reconsideration, hearing, or Appeals Council claim results in past-due benefits. We will tell you in
review; and writing the amount of the fee your representative can
o help you and your witnesses prepare for a hearing and charge based on the agreement.
question any witnesses.
If we do not approve the fee agreement, we will tell you
Also, your representative will receive a copy of the and your representative in writing. Then your
decision(s) we make on your claim(s). We will rely on your representative must file a fee petition to charge and collect
representative to tell you about the status of your claim(s), a fee.
but you still may call or visit us for information.
After we tell you the amount of the fee your representative
can charge, you or your representative can ask us to look at it
You and your representative(s) are responsible for giving
again if either or both of you disagree with the amount. (If we
Social Security accurate information. It is wrong to
approved a fee agreement, the person who decided your
knowingly and willingly furnish false information. Doing so
claim(s) also may ask us to lower the amount.) Someone who
may result in criminal prosecution.
did not decide the amount of the fee the first time will review
and finally decide the amount of the fee.
We usually continue to work with your representative until
(1) you tell us that he or she no longer represents you; or
(2) your representative tells us that he or she is withdrawing How Much You Pay
or indicates that his or her services have ended (for You never owe more than the fee we approve, except for:
example, by filing a fee petition or not pursuing an appeal).
We do not continue to work with someone who is suspended o any fee a Federal court allows for your
or disqualified from representing claimants. representative's services before it; and
o out-of-pocket expenses your representative incurs or
expects to incur, for example, the cost of getting your
What Your Representative(s) May Charge doctor's or hospital records. Our approval is not
Each representative you appoint can ask for a fee. To charge needed for such expenses.
you a fee for services, your representative must get our
Your representative may accept money in advance as long as
approval. (Even when someone else will pay the fee for you,
he or she holds it in a trust or escrow account. If an attorney
for example, an insurance company, your representative
represents you and your retirement, survivors, disability
usually must get our approval.) One way is to file a fee
insurance, or black lung claim results in past-due benefits, we
petition. The other way is to file a fee agreement with us. In
usually withhold 25 percent of your past-due benefits to pay
either case, your representative cannot charge you more than
toward the fee for you.
the fee amount we approve. If he or she does, promptly
report this to your Social Security office.
You must pay your representative directly:
o Filing A Fee Petition
o the rest of the fee you owe
Your representative may ask for approval of a fee by
- if the amount of the fee is more than any amount(s)
giving us a fee petition when his or her work on your
your representative held for you in a trust or escrow
claim(s) is complete. This written request describes in
account and we withheld and paid your attorney for
detail the amount of time he or she spent on each service
you.
provided you. The request also gives the amount of the
fee the representative wants to charge for these services. o all of the fee you owe
Your representative must give you a copy of the fee - if we did not withhold past-due benefits, for
petition and each attachment. If you disagree with the example, when your representative is not an
information shown in the fee petition, contact your attorney or the benefits are supplemental security
Social Security office. Please do this within 20 days of income; or
receiving your copy of the petition.
- if we withheld, but later paid you the money
We will review the petition and consider the reasonable because your attorney did not either ask for our
value of the services provided. Then we will tell you in approval until after 60 days of the date of your
writing the amount of the fee we approve. notice of award or tell us on time that he or she
planned to ask for a fee.
Form SSA-1696-U4 (4-2002) EF (4-2002)
Social Security Administration Form Approved
Please read the back of the last copy before you complete this form. OMB No. 0960-0527
Name (Claimant) (Print or Type) Social Security Number

Wage Earner (If Different) Social Security Number

Part I APPOINTMENT OF REPRESENTATIVE

I appoint this person, ,
(Name and Address)

to act as my representative in connection with my claim(s) or asserted right(s) under:

Title II Title XVI Title IV FMSHA Title XVIII Title VIII

(RSDI) (SSI) (Black Lung) (Medicare Coverage) (SVB)

This person 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).

I am appointing, or I now have, more than one representative. My main representative

is .
(Name of Principal Representative)

Signature (Claimant) Address

Part II ACCEPTANCE OF APPOINTMENT

I, , hereby accept the above appointment. I certify that I
have not been suspended or prohibited from practice before the Social Security Administration; that I am
not disqualified from representing the claimant as a current or former officer or employee of the United
States; and that I will not charge or collect any fee for the representation, even if a third party will pay
the fee, unless it has been approved in accordance with the laws and rules referred to on the reverse side
of the representative's copy of this form. If I decide not to charge or collect a fee for the representation,
I will notify the Social Security Administration. (Completion of Part III satisfies this requirement.)

I am an attorney. I am not an attorney. (Check one.)

Signature (Representative) Address

Telephone Number (with Area Code) Fax Number (with Area Code) Date

Part III (Optional) WAIVER OF FEE

I waive my right to charge and collect a fee under sections 206 and 1631(d)(2) of the Social Security
Act. I release my client (the claimant) from any obligations, contractual or otherwise, which may be
owed to me for services I have provided in connection with my client's claim(s) or asserted right(s).
Signature (Representative) Date

Part IV (Optional) ATTORNEY'S WAIVER OF DIRECT PAYMENT

I waive only my right to direct payment of a fee from the withheld past-due retirement, survivors,
disability insurance or black lung benefits of my client (the claimant). I do not waive my right to request
fee approval and to collect a fee directly from my client or a third party.
Signature (Attorney Representative) Date

Form SSA-1696-U4 (4-2002) EF (4-2002) (See Important Information on Reverse) REPRESENTATIVE'S COPY
Destroy Prior Editions
 INFORMATION FOR REPRESENTATIVES

Fees For Representation Collecting A Fee

An attorney or other person who wants to charge or You may accept money in advance, as long as you hold it
collect a fee for providing services in connection with a in a trust or escrow account. The claimant never owes you
claim before the Social Security Administration must first more than the fee we approve, except for:
obtain our approval of the fee for representation. The only
exceptions are if the fee is for services provided: o any fee a Federal court allows for your services
before it; and
o when a nonprofit organization or government
agency will pay the fee and any expenses from o out-of-pocket expenses you incur or expect to
government funds and the claimant incurs no incur, for example, the cost of getting evidence.
liability, directly or indirectly, for the cost(s); Our approval is not needed for such expenses.

o in an official capacity such as legal guardian, If you are not an attorney, you must collect the approved
committee, or similar court-appointed office and fee from the claimant.
the court has approved the fee in question; or
If you are an attorney, we usually withhold 25 percent of
o in representing the claimant before a court of any past-due benefits that result from a favorably decided
law. A representative who has provided retirement, survivors, disability insurance, or black lung
services in a claim before both the Social claim. Once we approve a fee, we pay you all or part of
Security Administration and a court of law may the fee from the funds withheld. We will also charge you
seek a fee from either or both, but neither the assessment required by section 206(d) of the Social
tribunal has the authority to set a fee for Security Act. You cannot charge or collect this expense
services provided before the other. from the claimant. You must collect from the claimant:

Obtaining Approval Of A Fee o the rest he or she owes

To charge a fee for services, you must use one of two, - if the amount of the fee is more than the
mutually exclusive fee approval processes. You must file amount of money we withheld and paid you
either a fee petition or a fee agreement with us. In either for the claimant, and any amount you held for
case, you cannot charge more than the fee amount we the claimant in a trust or escrow account.
approve.
o Fee Petition Process o all of the fee he or she owes
- if we did not withhold past-due benefits,
You may ask for approval of a fee by giving us a fee for example, because the benefits are
petition when you have completed your services to the supplemental security income or there are
claimant. This written request must describe in detail no past-due benefits; or if we withheld,
the amount of time you spent on each service provided but later paid the money to the claimant
and the amount of the fee you are requesting. because you did not either ask for our
approval until after 60 days of the date of
You must give the claimant a copy of the fee petition the notice of award or tell us on time that
and each attachment. The claimant may disagree with you planned to ask for a fee.
the information shown by contacting a Social Security
office within 20 days of receiving his or her copy of
the fee petition. We will consider the reasonable value Conflict Of Interest And Penalties
of the services provided, and send you notice of the
amount of the fee you can charge. For improper acts, you can be suspended or disqualified
from representing anyone before the Social Security
o Fee Agreement Process Administration. You also can face criminal prosecution.
Improper acts include:
If you and the claimant have a written fee agreement,
either of you must give it to us before we decide the o If you are or were an officer or employee of the
claim(s). We usually will approve the agreement if United States, providing services as a representative
you both signed it; the fee you agreed on is no more in certain claims against and other matters affecting
than 25 percent of past-due benefits, or $5,300 (or a the Federal government.
higher amount we set and announce in the Federal
Register), whichever is less; we approve the o Knowingly and willingly furnishing false information.
claim(s); and the claim results in past-due benefits.
We will send you a copy of the notice we send the o Charging or collecting an unauthorized fee or too
claimant telling him or her the amount of the fee you much for services provided in any claim, including
can charge based on the agreement. services before a court which made a favorable
decision.
If we do not approve the fee agreement, we will tell
you in writing. We also will tell you and the claimant
that you must file a fee petition if you wish to charge References
and collect a fee.
o 18 U.S.C. §§ 203, 205, and 207; 30 U.S.C. § 923(b);
and 42 U.S.C. §§ 406(a), 1320a-6, and 1383(d)(2)
After we tell you the amount of the fee you can charge, you
or the claimant may ask us in writing to review the approved o 20 CFR §§ 404.1700 et. seq., 410.684 et. seq., and
fee. (If we approved a fee agreement, the person who 416.1500 et. seq.
decided the claim(s) also may ask us to lower the amount.)
Someone who did not decide the amount of the fee the first o Social Security Rulings 88-10c (C.E. 1988), 85-3
time will review and finally decide the amount of the fee. (C.E. 1985), 83-27 (C.E. 1983), and 82-39 (C.E. 1982)
Form SSA-1696-U4 (4-2002) EF (4-2002)
Social Security Administration Form Approved
Please read the back of the last copy before you complete this form. OMB No. 0960-0527
Name (Claimant) (Print or Type) Social Security Number

Wage Earner (If Different) Social Security Number

Part I APPOINTMENT OF REPRESENTATIVE

I appoint this person, ,
(Name and Address)

to act as my representative in connection with my claim(s) or asserted right(s) under:

Title II Title XVI Title IV FMSHA Title XVIII Title VIII

(RSDI) (SSI) (Black Lung) (Medicare Coverage) (SVB)

This person 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).

I am appointing, or I now have, more than one representative. My main representative

is .
(Name of Principal Representative)

Signature (Claimant) Address

Telephone Number (with Area Code) Date

Part II ACCEPTANCE OF APPOINTMENT

I, , hereby accept the above appointment. I certify that I
have not been suspended or prohibited from practice before the Social Security Administration; that I am
not disqualified from representing the claimant as a current or former officer or employee of the United
States; and that I will not charge or collect any fee for the representation, even if a third party will pay
the fee, unless it has been approved in accordance with the laws and rules referred to on the reverse side
of the representative's copy of this form. If I decide not to charge or collect a fee for the representation,
I will notify the Social Security Administration. (Completion of Part III satisfies this requirement.)

I am an attorney. I am not an attorney. (Check one.)

Signature (Representative) Address

Telephone Number (with Area Code) Fax Number (with Area Code) Date

Part III (Optional) WAIVER OF FEE

I waive my right to charge and collect a fee under sections 206 and 1631(d)(2) of the Social Security
Act. I release my client (the claimant) from any obligations, contractual or otherwise, which may be
owed to me for services I have provided in connection with my client's claim(s) or asserted right(s).
Signature (Representative) Date

Part IV (Optional) ATTORNEY'S WAIVER OF DIRECT PAYMENT

I waive only my right to direct payment of a fee from the withheld past-due retirement, survivors,
disability insurance or black lung benefits of my client (the claimant). I do not waive my right to request
fee approval and to collect a fee directly from my client or a third party.
Signature (Attorney Representative) Date

Form SSA-1696-U4 (4-2002) EF (4-2002) (See Important Information on Reverse) OHA COPY
Destroy Prior Editions
 COMPLETING THIS FORM TO APPOINT A REPRESENTATIVE

Choosing To Be Represented How To Complete This Form, continued

You can choose to have a representative help you when you Sign your name, but print or type your address, your area
do business with Social Security. We will work with your code and telephone number, and the date.
representative, just as we would with you. It is important that
you select a qualified person because, once appointed, your Part II Acceptance of Appointment
representative may act for you in most Social Security Each person you appoint (named in part I) completes this
matters. We give more information, and examples of what a part, preferably in all cases. If the person is not an
representative may do, on the back of the "Claimant's Copy" attorney, he or she must give his or her name, state that
of this form. he or she accepts the appointment, and sign the form.
Paperwork and Privacy Act Notice
Part III (Optional) Waiver of Fee
The Social Security Administration will recognize someone
Your representative may complete this part if he or she
else as your representative if you sign a written notice
will not charge any fee for the services provided in this
appointing that person and, if he or she is not an attorney,
claim. If you appoint a second representative or
that person signs the notice agreeing to be your
co-counsel who also will not charge a fee, he or she also
representative. (You can read more about this in our
should sign this part or give us a separate, written waiver
regulations: 20 CFR §§ 404.1707, 410.684, and 416.1507.)
statement.
Giving the information this form requests is voluntary.
Without it though, we may not work with the person you
Part IV (Optional) Attorney's Waiver of
choose to represent you.
Direct Payment
How To Complete This Form
Your representative may complete this part if he or she is
Please print or type. At the top, show your full name and an attorney who does not want direct payment of all or
your Social Security number. If your claim is based on part of the approved fee from past-due retirement,
another person's work and earnings, also show the ''wage survivors, disability insurance, or black lung benefits
earner's'' name and Social Security number. If you appoint withheld.
more than one person, you may want to complete a form for
each of them. This information collection meets the clearance
requirements of 44 U.S.C. § 3507, as amended by section 2
Part I Appointment of Representative of the Paperwork Reduction Act of 1995. You are not
required to answer these questions unless we display a valid
Give the name and address of the person(s) you are
Office of Management and Budget control number. We
appointing. You may appoint an attorney or any other
estimate that it will take you about 10 minutes to read the
qualified person to represent you. You also may appoint more
instructions, gather the necessary facts, and answer the
than one person, but see ''What Your Representative(s) May
questions.
Charge'' on the back of the ''Claimant's Copy'' of this form.
You can appoint one or more persons in a firm, corporation,
References
or other organization as your representative(s), but you may
not appoint a law firm, legal aid group, corporation, or
o 18 U.S.C. §§ 203, 205, and 207; 30 U.S.C. § 923(b);
organization itself.
and 42 U.S.C. §§ 406(a), 1320a-6, and 1383(d)(2)
Check the block(s) showing the program(s) under which
o 20 CFR §§ 404.1700 et. seq., 410.684 et. seq., and
you have a claim. You may check more than one block.
416.1500 et. seq.
Check:
o Title Il (RSDI), if your claim concerns retirement, o Social Security Rulings 88-10c (C.E. 1988), 85-3
survivors, or disability insurance benefits. (C.E. 1985), 83-27 (C.E. 1983), and 82-39 (C.E. 1982)

o Title XVI (SSI), if your claim concerns

supplemental security income.

o Title IV FMSHA (Black Lung), if your claim

concerns black lung benefits under the Federal
Mine Safety and Health Act.

o Title XVIII (Medicare Coverage), if your claim

concerns entitlement to Medicare or enrollment in
the Supplementary Medical Insurance (SMI) plan.

If you will have more than one representative, check the

block and give the name of the person you want to be the
main representative.

Form SSA-1696-U4 (4-2002) EF (4-2002)