Form Ssa-1699 - Registration For Appointed Representative Services And Direct Payment Page 8
Download a blank fillable Form Ssa-1699 - Registration For Appointed Representative Services And Direct Payment in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ssa-1699 - Registration For Appointed Representative Services And Direct Payment with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8Section VII: General Attestations
MUST ATTEST
You
to these statements.
I will not divulge any information that SSA has furnished or disclosed about a claim or prospective claim, unless I have
the claimant's consent or there is a Federal law or regulation authorizing me to divulge this information.
I have in place reasonable administrative, technical, and physical security safeguards to protect the confidentiality of all
personal information I receive from SSA, to avoid its loss, theft, or inadvertent disclosure.
I will not omit or otherwise withhold disclosure of information to SSA that is material to the benefit entitlement or
eligibility of claimants or beneficiaries, nor will I cause someone else to do so, if I know or should know, that this would be
false or misleading.
I will not use Social Security program words, letters, symbols, branding, or emblems in my advertising or other
communications, in a way that conveys the false impression that SSA has approved, endorsed, or authorized me, my
communications, or my organization, or that I have some connection with or authorization from SSA.
I will update this registration if my personal, professional or business affiliation information changes, including
information related to disbarments, suspensions or sanctions.
I am aware that if I fail to comply with SSA laws and rules, I could be criminally punished by a fine or imprisonment or
both, and I could be subject to civil monetary penalties.
I understand that SSA will validate the information I provide.
I attest to all of the above.
Perjury Statement
I agree that a copy of this signed Form SSA-1699 will have the same force and effect as the original.
I declare under penalty of perjury that I have examined all of the information on this application and it is true and correct to the
best of my knowledge.
Signature of Person Identified in Section I
(You must sign your OWN name.)
Date
Form SSA-1699 (09-2013)
6
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal