Form Ssa-1699 - Registration For Appointed Representative Services And Direct Payment Page 3
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8Form Approved
Social Security Administration
OMB No. 0960-0732
REGISTRATION FOR APPOINTED REPRESENTATIVE SERVICES AND DIRECT PAYMENT
Complete all sections that apply to you. We will return incomplete or inaccurate forms.
Section I: Your Personal Identification and Home Contact Information
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All fields in this section are required unless indicated as optional. For your protection, we collect your home contact
information to check against our records.
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If you need to update information you provided on or after 10/31/09, include your name, Rep ID, and all information that has
changed. You must attest, sign, and date the updated form.
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Enter your name in the boxes below exactly as it appears on your Social Security card. If you want to use a different name,
contact your local Social Security office to change the name currently in our records. You must either receive a new card or
receive confirmation that we processed your name change prior to completing this form.
If you registered as an Appointed Representative on or after 10/31/09 and need to update your information,
enter your Rep ID below:
Your First Name
Your Middle Name
Your Last Name
Your Suffix (if any)
Your Date of Birth (MM/DD/YYYY)
Your Social Security Number
Your Home Mailing Address
Line 1
Street
Line 2
City
State
ZIP/Postal Code
Country (if outside the U.S.)
Your Daytime Telephone Number
Your Home Fax Number (Optional)
Country/Area Code
Phone Number
Extension
Country/Area Code
Fax Number
Your Email Address (Optional - Used for registration purposes and Social Security online service messages.)
Form SSA-1699 (09-2013)
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