GN 03910: Representation of Claimants
TN 8 (12-06)
List of Exhibits
Exhibit 1 - Model Representation Referral List
Exhibit 2 - Form SSA-1696-U4 (Appointment of Representative)
Exhibit 3 - Form SSA-L1697-U3 (Notice to Representative of Claimant Before the Social Security Administration)
Exhibit 4 - Form SSA-1128 (Representative Involved)
Exhibit 5 – Form SSA-1694 (Request for Business Entity Taxpayer Information)
Exhibit 6 – Form SSA-1695 (Identifying Information for Possible Direct Payment of Authorized Fees)
Exhibit 7 – Form SSA-1699 (Registration for Appointed Representative Services and Direct Payment)
Exhibit 8 – Preprinted Notice (Return of the Form SSA-1695 and/or SSA-1699)
Exhibit 9 – Preprinted Notice (SSA-1695 Acknowledgement of Receipt and Input)
A. Exhibit 1 - Model Representation Referral List
IMPORTANT NOTICE
IF YOU WANT TO OBTAIN A PRIVATE ATTORNEY to represent you and you need assistance in obtaining an attorney's services, you may contact one of the organizations shown below. They can refer you to a private attorney who is familiar with representing claimants before the Social Security Administration. Some private attorneys may be willing to take your case under an arrangement in which he or she will not charge a fee unless your claim is allowed. The attorney must obtain the Social Security Administration's authorization for any fee he or she wants to charge and collect.
These organizations have indicated that they want to be included on this list. The Social Security Administration has made no attempt to evaluate their services.
|
NAME AND ADDRESS |
SERVICES |
|---|---|
|
Lawyers Referral Services 629 Municipal Courts Building 111 N. Wilson Street Anytown, USA Phone: 123-4561 Lawyers Referral Services825 South Courthouse Square Anyville, USA Phone: 123-4567 |
Serves claimants residing in Anytown. |
IF YOU ARE NOT ABLE TO PAY FOR REPRESENTATION and you believe you might qualify for free legal representation, you should contact one of the following organizations:
|
NAME AND ADDRESS |
SERVICES |
|---|---|
|
Anyplace County Legal Services Organization 815 Wilmington Avenue Anyplace, USA Phone: 123-4563 |
Serves claimants residing in Anyplace County. |
COMMUNITY ORGANIZATIONS that may provide you with non-attorney representation are:
|
Veterans of Foreign Wars 100 Veterans Avenue Anyplace, USA Phone: 123-4564 |
Provides paralegals and other non-attorney representatives for qualifying veterans who reside in the metropolitan Anyplace area. |
|
Disabled American Veterans 100 Downtown Boulevard Anyville, USA Phone: 123-4565 |
Provides paralegals and other non-attorney representatives for disabled American veterans residing in the metropolitan Anyville area. |
|
Any State University Community Legal Clinic 100 University Boulevard Anyville, USA Phone: 123-4566 |
Provides paralegals and other non-attorney representatives for claimants living in southwestern Any State. |
|
Anytown University College of Law 100 College Avenue Anytown, USA Phone: 123-4567 |
Provides paralegals and other non-attorney representatives for claimants living in greater Anytown. |
B. Exhibit 2 - Form SSA-1696-U4 (Appointment of Representative) File Copy
Select Form SSA-1696-U4 to obtain the most current pdf.
C. Exhibit 3 - Form SSA-L1697-U3 (Notice to Representative of Claimant Before the Social Security Administration)
To view this form, go to SSA-L1697-U3.
D. Exhibit 4 - Form SSA-1128 (Representative Involved)
Select Form SSA-1128 for the most current pdf.
E. Exhibit 5 – Form SSA-1694 (Request For Business Entity Taxpayer Information)
Select Form SSA-1694 for the most current pdf.
F. Exhibit 6 – Form SSA-1695 (Identifying Information for Possible Direct Payment of Authorized Fees)
Select Form SSA-1695 for the most current pdf.
G. Exhibit 7 – Form SSA-1699 (Registration for Appointed Representative Services and Direct Payment)
Select Form SSA-1699 for the most current pdf.
H. Exhibit 8– Preprinted Notice (Return of Form SSA-1695 and/or SSA-1699)
Click on View PDF Version to print out a copy of the notice you want to fill out.
Notice 1
Notice 2
Notice 3
I. Exhibit 9 – Preprinted Notice (SSA-1695 Acknowledgement of Receipt and Input)
Field Office Address
Street
City, STATE ZIP CODE
MM, DD, YYYY
Representative Name
Street Address
City, State, Zip Code
Dear Mr/Ms. [Addressee Last Name]
We are writing to tell you that we processed the Form SSA-1695, (Identifying Information for Possible Direct Payment of Authorized Fees) that you submitted for [NH first/last name]. We masked your Social Security Number to protect your privacy and return the processed form for your records.
If You Have Any Questions
For general information about the Claimant Representative Registration process, visit our Representing Claimants website at www.socialsecurity.gov/representation/ . If you have questions about reporting income or Form 1099–MISC, please contact the Internal Revenue Service.
Field Office Manager Signature