TN 8 (12-06)

GN 03910.090 Representation of Claimants - Exhibits

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 Services
825 South Courthouse Square
Anyville, USA

Phone: 123-4567

Serves claimants residing in Anytown.




Serves claimants residing in Anyplace County.

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)

G-SSA-L1697-U3

 View PDF Version

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 1 - Return of Form SSA-1695

 View PDF Version

Notice 2

Notice 2 - Return of Form SSA-1699

 View PDF Version

Notice 3

Notice 3 - Return of Form SSA-1695 and/or SSA1699

 View PDF Version

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

 View PDF Version


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0203910090
GN 03910.090 - Representation of Claimants - Exhibits - 03/19/2012
Batch run: 03/19/2012
Rev:03/19/2012