View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0960-0527
ICR Reference No:
202005-0960-012
Status:
Historical Active
Previous ICR Reference No:
201910-0960-001
Agency/Subagency:
SSA
Agency Tracking No:
Title:
Appointment of Representative
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
06/04/2020
Retrieve Notice of Action (NOA)
Date Received in OIRA:
05/27/2020
Terms of Clearance:
The agency will ensure that the revised version of the SSA-1696 will have fully fill-able fields for all fields related to SSNs and Rep ID numbers. Prior to rebusmission of this ICR Prior to resubmission of this ICR, the agency will ensure the the signature field is fully fillable as well
Inventory as of this Action
Requested
Previously Approved
Expiration Date
06/30/2022
06/30/2022
06/30/2022
Responses
1,054,000
0
1,054,000
Time Burden (Hours)
181,167
0
181,167
Cost Burden (Dollars)
0
0
0
Abstract:
Recipients use Form SSA-1696 to appoint a representative to handle their claim before SSA. Recipients’ representatives use the Form SSA-1696 to indicate whether they will charge a fee, and, if so, specify their eligibility for direct fee payment. The representatives also use Form SSA 1696 to indicate their disbarment or suspension from a court or bar in which they previously admitted to practice, or their disqualification from participating in or appearing before a Federal program or agency. SSA recognizes the recipient’s representative as the individual named in a notice of appointment (or written statement), which the recipient signed and filed at an SSA office. The SSA 1696 (or written statement) documents the appointment of a representative. We also use this form to collect the business affiliation and EIN of the representatives. Our regulations also require that if the representative is a non attorney, they must sign the form or equivalent written statement. In addition, respondents use the SSA 1696-SUP1 to revoke their appointment of a representative, and representatives use the SSA 1696-SUP2 to withdraw their acceptance of the appointment. SSA uses this information to document the revocation and withdrawal of a representative. Respondents are applicants for, or recipients of, Social Security disability benefits (SSDI); SSI payments; or anyone pursuing a benefit or invoking a right under SSA programs, who are notifying SSA they have appointed a person to represent them in their dealings with SSA, and their non attorney representatives who need to sign the form. This is a non-substantive Change Request to make minor revisions to the form to remove redundancies, and clarify language.
Authorizing Statute(s):
US Code:
42 USC 406
Name of Law: Social Security Act
US Code:
42 USC 1383
Name of Law: Social Security Act
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
83 FR 31987
07/10/2018
30-day Notice:
Federal Register Citation:
Citation Date:
84 FR 4597
02/15/2019
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
3
IC Title
Form No.
Form Name
Appointment of Representative - SSA-1696
SSA-1696
Appointment of Representative
Claimant's Revocation of the Appointment of a Representative - SSA-1696-SUP1
SSA-1696-SUP1
Claimant's Revocation of the Appointment of a Representative
Representative's Withdrawal of Acceptance of an Appointment - SSA-1696-SUP2
SSA-1696-SUP2
Representative's Withdrawal of Acceptance of an Appointment
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
1,054,000
1,054,000
0
0
0
0
Annual Time Burden (Hours)
181,167
181,167
0
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$36,900
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Yes
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Yes
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
Yes
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
Yes
Is this ICR related to the Pandemic Response?
No
Agency Contact:
Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
05/27/2020
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