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
477-04-5900 5F5TQG5NYN
Claimant's Appointment of a Representative
Section 1 - Claimant's Information
First Name Initial Last Name
Lisa Marie Kaml
Mailing Address
629 6th Ave S
City State ZIP/Postal Code Country – if outside the
Grand Forks ND 58201 U.S.
Phone Number Alternate Phone Number (Optional)
(701) 317-3011
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 Jason Robert Emery
Form SSA-1696 (08-2020) UF Page 4 of 6
Claimant's Social Security Number Appointed Representative's Rep ID
477-04-5900 5F5TQG5NYN
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 [Link]/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
Jason R Emery
Mailing Address
MLG Disability PLLC
7380 France Avenue South – Suite 250
City State ZIP/Postal Code Country – if outside the
Edina MN 55435 U.S.
Phone Number Alternate Phone Number (Optional)
952-224-9196
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 [Link]/representation for criteria).
I am a non‐attorney not eligible for direct payment.
I work for 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
477-04-5900 5F5TQG5NYN
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 87-1746527
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) MLG Disability PLLC
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 agree that 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 JRE (Representative’s Initials)
Form SSA-1696 (08-2020) UF Page 6 of 6
Claimant's Social Security Number Appointed Representative's Rep ID
477-04-5900 5F5TQG5NYN
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)
Date
Representative's Signature
August 11, 2022
Claimant's Signature Date
August 11, 2022
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
477-04-5900 Y9D7RJG5VW
Claimant's Appointment of a Representative
Section 1 - Claimant's Information
First Name Initial Last Name
Lisa Marie Kaml
Mailing Address
629 6th Ave S
City State ZIP/Postal Code Country – if outside the
Grand Forks ND 58201 U.S.
Phone Number Alternate Phone Number (Optional)
(701) 317-3011
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 Jason Robert Emery
Form SSA-1696 (08-2020) UF Page 4 of 6
Claimant's Social Security Number Appointed Representative's Rep ID
477-04-5900 Y9D7RJG5VW
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 [Link]/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
Daniel T Yates
Mailing Address
MLG Disability PLLC
7380 France Avenue S – Suite 250
City State ZIP/Postal Code Country – if outside the
Edina MN 55435 U.S.
Phone Number Alternate Phone Number (Optional)
952-224-9196
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 [Link]/representation for criteria).
I am a non‐attorney not eligible for direct payment.
I work for 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
477-04-5900 Y9D7RJG5VW
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 87-1746527
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) MLG Disability PLLC
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 agree that 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 DTY (Representative’s Initials)
Form SSA-1696 (08-2020) UF Page 6 of 6
Claimant's Social Security Number Appointed Representative's Rep ID
477-04-5900 Y9D7RJG5VW
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)
Date
August 11, 2022
Representative's Signature
Claimant's Signature Date
August 11, 2022
FEE AGREEMENT
I, Lisa Marie Kaml, retain and employ Daniel T. Yates and Jason R. Emery of the law firm
MLG Disability 7380 France Avenue South Suite 250 Edina, MN 55435, to represent me in my
claim(s) for benefits under the Social Security Act, as amended. If I do not get Social Security
benefits, I will not have to pay any attorney fees. I agree that my attorney’s fee will be the
lesser of 25% of all past-due benefits awarded to my family and me, or the dollar amount
established pursuant to 42 U.S.C. sec. 406(a)(2)(A), which is currently $6,000.00 (as of June
22, 2009, and was $5,300 prior to that time), but which may be increased from time to time
by the Commissioner of Social Security. I understand that my attorney may advance out-of-
pocket costs for medical records or other documentation. My attorney agrees to make a
reasonable effort to obtain my prior approval before spending any such money. I agree to
reimburse my attorney for these out of pocket costs at the conclusion of my case, but I will not
have to reimburse any out-of-pocket costs unless I win my case and am awarded benefits.
We understand that one or both of us may request review of the fee amount, in writing, within 15
days after SSA has notified us of any amount my attorney can charge. If SSA approved the fee
agreement, the person(s) who decided my claim(s) may ask for a reduction of the fee under the
agreement if, in his or her opinion, my attorney did not represent my interests adequately or the
fee is clearly excessive for the services provided. I understand that my attorney has not promised
to win my case, but has only promised to his best to represent me in my claim. I understand that
this agreement may be canceled by either party at any time, for any reason. I agree to notify my
attorney of his termination in writing, by U.S. mail, sent to said attorney’s office address. Daniel
T. Yates, Jason R. Emery, and/or MLG Disability agree to notify me of their withdrawal by U.S.
mail to my last known address and give notice to the agency which may be processing my claim
at that particular time. This will acknowledge that I have read and received a copy of this
Fee agreement, which was signed on:
DATE: August 11, 2022
CLAIMANT: __________________________ SSN: 477-04-5900
Lisa Marie Kaml
ATTORNEY:
Jason R. Emery Daniel T. Yates