Form Ssa-1699 - Registration For Appointed Representative Services And Direct Payment Page 5

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Section IV: Your Information as a Representative
All representatives must complete this section.
1. Your Address for Receipt of Notices
Same as Home Address in Section I
Street
Line 1
Line 2
City
State
ZIP/Postal Code
Country(if outside the U.S.)
Business Telephone Number (if different from that
Business Fax Number (Optional)
2.
provided in Section I.)
Country/Area Code
Phone Number
Extension
Country/Area Code
Fax Number
3. Business Email Address (Optional)
4.
Yes
Did you check “Yes” in Section II OR have you been notified by us
that you are eligible for direct payment of your fees?
No
(Go to Section VI)
5.
What is your preferred payment method?
Direct Deposit to U.S. Bank – I am the owner or co-owner of this account. (You must be the
owner or co-owner)
Checking
Savings
Type of Financial Account:
Routing Number
Account Number
OR
Check – Will be mailed to the Notice Address
6.
Same as Home Address
Your Tax Address (This is the address where
we will send your FORM 1099-MISC)
Same as Notice Address in 1 in this section
Street
Line 1
Line 2
City
State
ZIP/Postal Code
Country(if outside the U.S.)
Form SSA-1699 (09-2013)
3

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