Field Office Address
City, STATE ZIP CODE
MM, DD, YYYY
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