Form Ssa-1695 - Identifying Information For Possible Direct Payment Of Authorized Fees
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1Form 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
Marc J. Shefman
City
P.O. Box, Street, Apt., or Suite No.
17000 W Ten Mile Rd. Ste 150
Southfield
State
ZIP Code or Postal Zone
Country
MI
48075
USA
Phone Number
Fax Number
(including area code)
(optional)
(248) 298-3003
(248) 559-7710
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
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