Ssa-1695, 2006, Identifying Information For Possible Direct Payment Of Authorized Fees printable pdf download

Ssa-1695, 2006, Identifying Information For Possible Direct Payment Of Authorized Fees

Form Approved

Social Security Administration

OMB No. 0960-0730

Identifying Information for Possible Direct Payment of Authorized Fees

Information About the Claimant

First Name

Middle Name

Last Name

Social Security Number

Suffix

Wage Earner's Name if different than above

Wage Earner's Social Security Number if different

Type of Benefits

Title II (RSDI)

Title XVI (SSI)

Information about You, the Representative

Name

Social Security Number

City

P.O. Box, Street, Apt., or Suite No.

State

ZIP Code or Postal Zone

Country

Phone Number

Fax Number

(including area code)

(optional)

Employer Identification Number (EIN), if applicable.

If you are representing the claimant(s) as a partner or

an employee of a firm or other business entity, you may provide the EIN of the firm or business. See instructions

on Page 2 for more information.

Information about Other Claimants You are Representing in Connection with this Claim

List below the Social Security Numbers and names of all other claimants not mentioned above. If all

claimants will not fit on this form, list on a separate form or blank paper.

Claimant's Name

Claimant's Social Security Number

To SSA STAFF: After the information on this form is entered into the appropriate system(s),

immediately shred the form. Under no circumstances should this form be scanned, placed in a claims

file or otherwise retained.

Form SSA-1695 (09-2006)

Page 1

Ssa-1695, 2006, Identifying Information For Possible Direct Payment Of Authorized Fees