Form Ssa-1699 - Registration For Appointed Representative Services And Direct Payment Page 7
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8Section VI: Attestations and Questions for Representation
MUST ATTEST
You
to these statements and complete the following questions.
I understand and will comply with SSA laws and rules relating to the representation of parties, including the Rules of
1.
Conduct and Standards of Responsibility for Representatives.
I will not charge, collect, or retain a fee for representational services that SSA has not approved or that is more than
SSA approved, unless a regulatory exclusion applies.
I will not threaten, coerce, intimidate, deceive, or knowingly mislead a claimant or prospective claimant, or beneficiary,
regarding benefits or other rights under the Social Security Act.
I will not knowingly make or present, or participate in making or presenting, false or misleading oral or written
statements, assertions, or representations about a material fact or law concerning a matter within SSA's jurisdiction.
I am aware that if I fail to comply with any SSA laws and rules relating to representation, I may be suspended or
disqualified from practicing as a representative before SSA.
I attest to all of the above.
2. Have you ever been:
a.
Suspended or prohibited from practice before SSA or any
Yes (Explain below.)
other Federal program or agency?
No
Disbarred or suspended from a court or bar to which you were
b.
Yes (Explain below.)
previously admitted to practice as an attorney?
No
Convicted of a violation under Section 206 or 1631(d) of the
c.
Yes (Explain below.)
Social Security Act?
No
d.
Disqualified from representing a claimant as a current or former
Yes (Explain below.)
officer or employee of the United States?
No
3. For each Yes answer in 2, provide the information below regarding that event (Attach copies of this page if you need
more space.)
Federal Program or Agency;
or Court or Bar Name:
Bar Number (provide the Bar Number if you
have one AND you answered “Yes” to 2b):
Year Admitted (provide the year
if you answered “Yes” to 2b):
Beginning Date of:
Ending Date: (if ended)
Brief Description of Circumstances:
Form SSA-1699 (09-2013)
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