Social Security Administration OMB No.

0960-0699
Eligible Non-Attorney Representative
You must complete this application carefully and provide all supporting documentation as required. You must provide all
required information once you pass the examination in order to receive direct payment of fees. If you have any
questions, please access the Attorneys and Appointed Representatives Website at http://www.ssa.gov/representation/.

Purpose of this Form Acceptable forms of fee payment will be by

Section 3 of the Social Security Disability check, money order, or a check drawn from a
Applicants’ Access to Professional private firm's account;
Representation Act (PRA) Public Law no.111-
142 provides for permanent extension of direct Applicants will pay their fees to the entity
payment of SSA-approved fees to certain non- listed on the Attorneys and Appointed
attorney representatives. Under the PRA, to be Representatives Website at
eligible for direct payment of fees, a non- http://www.ssa.gov/representation/; and
attorney representative must fulfill the following
statutory prerequisites: (1) possess a Applicants found ineligible to take the
bachelor’s degree or have equivalent examination or who fail the examination may
qualifications derived from training and work apply in any future application period, but must
experience; (2) pass an examination that tests then again pay the full fee.
knowledge of the relevant provisions of the
Social Security Act; (3) secure professional Education and Equivalent Qualifications
liability insurance or equivalent insurance; (4) A bachelor’s degree from an accredited
pass a background check; and (5) demonstrate institution of higher education is a prerequisite
completion of relevant continuing education to receive direct payment of fees. Applicants
courses. who do not have a bachelor’s degree may
satisfy this prerequisite based on a
SSA must collect the requested information to combination of holding a high school diploma
determine if a non- attorney representative or general education diploma (GED) plus four
has met the prerequisites to be eligible for years of relevant professional experience that
direct payment of fees for his or her claimant the Commissioner determines to be equivalent
representation services. The information to a bachelor’s degree.
collection is needed to comply with the
legislation. The respondents are non-attorney Relevant professional experience is training or
representatives who apply for direct payment work through which the applicant
of fees. demonstrates familiarity with medical reports
and an ability to describe and assess
Application Fee mental and/or physical limitations. Such
PRA section 3(a) provides that the experience may be from the fields of: teaching,
Commissioner may assess applicants a counseling or guidance, social work,
reasonable fee to cover the costs of personnel management, public employment
administering the prerequisites process. The service, and/or nursing or other health care
non-refundable fee is listed on the Attorneys professional services. Professional work
and Appointed Representatives Website at involving claims for benefits under title II or
http://www.ssa.gov/representation/; title XVI of the Act is considered relevant
professional experience.
Applicants must include the non-refundable fee
payment with their application package; An applicant must submit proof of a
bachelor’s degree or equivalent
qualifications after he or she passes the

Form SSA-1691 Page 1

examination. Failure to do so precludes the coverage in order to continue to receive direct
applicant from establishing his or her eligibility payment of fees from SSA.
to receive direct payment of fees. Proof of
education is an official transcript showing the Background Check
stamp or raised seal. Proof of relevant A background check is required of each
professional experience includes, but is not applicant to ensure his or her fitness to
limited to an Internal Revenue Service (IRS) practice before SSA. SSA rejects any applicant
Form W-2(s), Wage and Tax Statement(s), who:
and letters from employers.
• has been suspended or disqualified
Attorneys who have fees paid directly from from practice before SSA;
their clients' past-due benefits pursuant to
• has had a judgment or lien assessed
sections 206 and 1631(d)(2) of the Act are not against him/her by a civil court for
required to take the examination. Attorneys who
malpractice and/or fraud;
are suspended or disbarred by a State or
Federal court or disqualified from appearing • has had a felony conviction;
before a Federal agency or program are not
eligible to receive direct payment and should not • has failed to provide the required
submit an application. documentation enabling SSA to
perform the criminal background
Types of Insurance investigation;
Applicants are required to have professional
liability insurance or equivalent insurance, • has substantially misrepresented the
which the Commissioner has determined to facts in submitting his or her application;
be adequate to protect claimants in the event
of malpractice by the non-attorney • fails to pass an SSA administrative
representative. The insurance policy must be records check (check of SSN, etc.).
underwritten by a firm that is licensed to
provide insurance in the State in which the Examination
non-attorney representative conducts business. Applicants are required to pass an
The policy must also provide coverage for examination testing their knowledge of the
professional liability insurance claims made in relevant provisions of the Act and the most
those States in which the non-attorney recent developments in Agency and court
representative represents claimants before decisions affecting titles II and XVI of the Act.
SSA. The examination will consist of 40 to 50
multiple-choice questions. Examination details
See the Attorneys and Appointed are as follows:
Representatives Website at
http://www.ssa.gov/representation/ for • The examination instrument is written in
professional and business liability insurance the English language only;
coverage amounts. • The examination will be given only once,
on a weekday, in conjunction with each
An applicant must submit proof of the application period;
required insurance after he or she passes the
examination. Failure to do so precludes the • During the examination, test-takers will
applicant from establishing his or her eligibility have open-book access to certain
to receive direct payment. An applicant who reference materials that we will supply
establishes eligibility to receive direct payment (see below for details);
will be required to maintain insurance

Form SSA-1691 Page 2

 titles II and XVI of the Act. We will prescribe
the course(s) and notify eligible non-attorney
• The examination will be based upon representatives of when to complete and how
situations that arise from the subject to certify that they have completed the
areas contained in the reference course(s).
materials.
Instructions for Completing this Form
• Applicants will not be permitted to
• Please type or print legibly using only a
remove the examination instrument or
BLUE or BLACK ink pen.
reference materials from the
examination center.
• Completely fill out all sections of this
Open-book reference materials provided by form. Use "None" or "N/A" where
SSA are listed below. Applicants will not be applicable.
permitted to bring any other items (including
reference materials) to the examination center. • Include an area code with all telephone
numbers.
• One copy of the 20 C.F.R., Chapter III
(Parts 400- 499), and • Include a zip code with all addresses.
• One copy of the Compilation of
Social Security Laws, Volume 1. • List your full middle name. If you do
not have a middle name, please indicate
Applicants who fail to achieve a passing score this by showing "NMN" for a middle
may re-apply during a subsequent application name.
period; however, they will be required to pay
the application fee again. • Line out and initial any changes you
make to your application.
Continuing Education Courses (CE)
Applicants who become eligible non-attorney • If you require additional space, please
representatives must complete courses to use Section D. Please indicate the
meet the continuing education requirement. section and question number you are
The courses must enhance eligible non- responding to before you record the
attorney representatives’ professional additional information.
knowledge in matters such as those related to
entitlement to benefits, ethics, listing of
impairments, and other disability topics under

Form SSA-1691 Page 3

 OMB No. 0960-0699

Please read the instructions on pages 1 through 3 of this application for eligibility requirement.

SECTION A Background Information – Applicant’s Identifying Information

First Name: Full Middle Name: Last Name: Suffix:

Other Name(s) Used:

Reason(s) for other name(s) used:

SSN: Date of Birth (mm/dd/yyyy):

Citizenship Status:

---- U.S. Citizen ---- Naturalized Citizen ---- Alien Authorized to work in the U.S. ---- Other If other, please specify:

SECTION A Background Information – Applicant’s Contact Information

Address: Home Phone:

Address (Line 2): Mobile Phone:

City: State: Zip Code: Work Phone:

E-mail Address:

SECTION A Background Information – Additional Information

1. Are you a licensed or practicing attorney? ---- Yes ---- No

OR
Are you an attorney who has been disbarred or suspended from practicing in any
state?

If yes to either of these questions, stop. Do not submit this application. Licensed or
practicing attorney are not required to take the examination in order to receive direct
pay. Disbarred or suspended attorneys are not eligible to take the examination.

2a. Do you have a bachelor’s degree from an accredited institution of higher ---- Yes ---- No
education? (If Yes, go to question 3. If No, please answer question 2b.)

2b. Do you have equivalent qualifications? (Only respond if you answered ---- Yes ---- No
No to question 2a.)

SECTION A Background Information – Additional Information (continued)

Form SSA-1691 Page 4
3. Have you been, by reason of misconduct, disqualified, sanctioned, or suspended
from participating in any Federal program or appearing before the Social Security ---- Yes ---- No
Administration or any other Federal Agency?

Name of Program or Agency:

If Yes, please provide the following information:
Address of Program or Agency:

Details of Disqualification, Sanction or Suspension:

Date of disqualification, sanction or Date of Reinstatement (if

suspension: applicable):

4. Are you currently being investigated by reason of misconduct, by the Social Security ---- Yes ---- No
Administration or any other Federal agency for possible disqualification, sanction, or
suspension?

Name of Program or Agency:

If Yes, please provide the following information:
Address of Program or Agency:

Details of Investigation:

Details of Investigation: Status of Investigation:

5. Have you been determined to have fraudulently used or misused any Social Security ---- Yes ---- No
benefits?

6. Have you had a judgment or lien assessed against you by a civil court for ---- Yes ---- No
malpractice and/or fraud?

7. Have you ever had a felony conviction? ---- Yes ---- No

8. Have you been determined to have violated any Social Security program rules (e.g., ---- Yes ---- No
rules regarding the disclosure of evidence or representative payee rules)?

9. Have you applied for the Social Security Administration Non-Attorney Representative ---- Yes ---- No
Examination before?

Date of Previous Application(s):

If yes, please provide the following information:
Disposition of Previous Application:

Any Changes to Report Since Previous Application:

SECTION B Education/Equivalent Qualifications – College/University Attended

Form SSA-1691 Page 5

Please provide information on the accredited College or University from which you received your bachelor’s degree or
higher. Once you pass the examination, you must provide proof of your highest degree in the form of an official transcript
showing the stamp or raised seal, or otherwise establishing that it is an official copy.
Name of College/University: City: State:

Attended From (mm/yyyy): Attended To (mm/yyyy): Degree Granted? ---- Yes ---- No

Indicate degree granted: ---- Doctorate Degree ---- Graduate Degree ---- Bachelor’s Degree
SECTION B Education/Equivalent Qualifications – High School Diploma or GED
If you do not have a bachelor’s degree or higher from an accredited College or University, you must provide
information regarding your High School Diploma or GED. Once you pass the examination, you must provide proof in the
form of a copy of your high school transcripts, diploma, or GED certificate (or other equivalent documentation).
High School or GED Certificate: Date Diploma or Certificate Awarded (mm/yyyy):

City: State:

SECTION B Education/Equivalent Qualifications – Relevant Professional Experience

If you have a bachelor’s degree or higher, skip this section. If you do not have a bachelor’s degree or higher, provide
information about relevant professional experience. You must provide four years of relevant training or work experience
through which you have demonstrated familiarity with medical reports and an ability to describe and assess mental
and/or physical limitations. Such experience may be from the fields of: teaching, counseling or guidance, social work,
personnel management, public employment service, and/or nursing or other health care professional services. Any work
experience involving claims for benefits under title II or title XVI of the Act shall also be defined as relevant professional
experience. In the Position Description field, you must add enough detail for SSA to determine if the cited experience
constitutes relevant professional experience. Once you pass the examination, you must provide proof (e.g., IRS Form W-2,
wage and tax Statement (s)) of your professional experience.
1. This experience is: ---- SSA Related Professional Experience ---- Other Professional Experience
Position/Title:

Position Description:

Name of Employer:

Address:

City: State: Zip Code:

Name of Supervisor: Employer Phone:

2. This experience is: ---- SSA Related Professional Experience --- Other Professional Experience
Position/Title:

Position Description:

Name of Employer:

Address:

City: State: Zip Code:

Name of Supervisor: Employer Phone:

If you require additional space, please use Section D

Form SSA-1691 Page 6

SECTION C Examination Information
The exam will be administered at designated locations across the country. The exam will be held on the same date at each
location. SSA may cancel any site if enrollment does not meet minimum standards. In that event, applicants will be
notified at least 20 days prior to the test date in order make appropriate travel arrangements to an alternate test site. See
the Attorneys and Appointed Representatives Website at http://www.ssa.gov/representation/ for a list of exam locations.

Applicants will be asked to select a first and second choice for their examination location (for use if they pass a criminal
background check and are eligible to sit for the exam). Applicants who timely submit their applications but fail to select a
second choice will have their applications denied as incomplete. Applicants who timely submit their applications but repeat
their first choice as their second choice will be contacted and given the opportunity to correct the defect by selecting a
second choice examination site that is different from the first choice examination site. This information will be used by SSA
in the event the first choice examination site is cancelled. Please provide your top two (2) choices for your
examination location. Detailed information concerning the specific location of the examination site will be mailed to those
applicants determined eligible to sit for the examination.
First Choice Location City: State:

Second Choice Location City: State:

SECTION C Examination Information – Special Accommodation Request

Please describe any special accommodation you will need at the examination location. Please note that you must provide
supporting documentation from a professional qualified to determine your condition along with your application to the
address indicated on the Attorneys and Appointed Representatives Website at http://www.ssa.gov/representation/.

Please initial indicating that you understand that you must provide written documentation to support Initials:
your request for special accommodations along with your application.

Form SSA-1691 Page 7

SECTION D Additional Information

Form SSA-1691 Page 8

 Privacy Act Statement

Collection and Use of Personal Information

Section 3 of the Social Security Disability Applicants’ Access to Professional Representation Act of 2010, authorizes us to
collect this information. We will use the information you provide to further document your application and permit a
determination about your eligibility to receive direct payment of fees (from a claimant’s past-due benefits) for your
representation services.

The information you furnish on this form is voluntary. However, failure to provide the requested information could result in
a determination that you are ineligible to receive direct payment of fees.

We rarely use the information you supply for any purpose other than for determining eligibility to receive direct payment of
fees. However, we may use it for the administration and integrity of Social Security programs. We may also disclose
information to another person or to another agency in accordance with approved routine uses, which include but are not
limited to the following:

1. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veterans Affairs);

2. To employers of claimants’ representatives, to assist in collecting debts owed by representatives who

received an excess or erroneous representational fee payment and owe a delinquent debt, or as necessary
for us to carry out the requirements for fee reporting to appointed representatives; and

3. To facilitate audit or investigative activities necessary to assure the integrity of Social Security programs.

We may also use the information you provide in computer matching programs. Matching programs compare our records
with records kept by other Federal, State, or local government agencies. Information from these matching programs can
be used to establish or verify a person’s eligibility for Federally funded or administered benefit programs and for
repayment of payments or delinquent debts under these programs.

A complete list of routine uses for this information is available in our Systems of Records Notice 60-0325 (Appointed
Representative File). The Notice, additional information about this form, and information regarding our systems and
programs, are available on-line at www.socialsecurity.gov or at your local Social Security office.
Please initial indicating that you have read and understand the Privacy Act Statement. Initials:

Form SSA-1691 Page 9

 Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of
1995. You do not need to answer these questions unless we display a valid Office of Management Budget control number. We
estimate that it will take 30 - 45 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
Please initial indicating that you have read and understand the Paperwork Reduction Act Initials:
Statement.
Substantial Misrepresentation or Material Discrepancy Statement
If I cannot substantiate my application or it is determined that the information I entered is incorrect, I understand
that I may be determined ineligible to sit for the examination or to receive direct payment of fees.
Please initial indicating that you have read and understand the Substantial Misrepresentation or Initials:
Material Discrepancy statement.
Application Fee Statement

The application fee is non-refundable. See the Attorneys and Appointed Representatives Website for additional
information.
Please initial indicating that you have read and understand the statement regarding the applicable Initials:
fee.
Statement of Understanding
I understand that I must sign the application in ink and submit the application fee and complete application package to
the address indicated on the Attorneys and Appointed Representatives Website at
http://www.ssa.gov/representation/. I also understand that I will be required to complete, sign, and submit a release
form necessary for the criminal background check with this application.

This application package must be postmarked or receipt-dated (if sent by private express service) by midnight
E.D.T. of the last day of the application period. I further understand that the application fee is generally non-
refundable. SSA will not process my application until the completed application package is received. If this
requirement is not met as of midnight E.D.T. of the last day of the application period, SSA will process my
application as a denial. See the Attorneys and Appointed Representatives Website at
http://www.ssa.gov/representation/ for information about the application period.
Please initial indicating that you have read and understand the Statement of Understanding Initials:
statement:
Penalty of Perjury Statement
I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that
anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes
someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.
Signature (sign in ink) Date:

Form SSA-1691 Page 10

 OMB o. 0960-0699

Social Security Administration

PLEASE READ CAREFULLY

APPLICANT AUTHORIZATION FOR RELEASE OF INFORMATION

I authorize SSA to conduct a criminal background check in which SSA may secure any criminal history information
pertaining to me that may be in the files of any Federal, State, or Local criminal justice agency. I authorize any
Federal, State, or Local criminal justice agency to release to SSA any criminal history information pertaining to me
that may be in the agency’s files. I authorize SSA, and any of its agents, to disclose orally and in writing the results
of this criminal background check to the business entity that manages the information for managing direct payment
eligibility for non-attorney representatives.

I understand that the results of the criminal background check may be used by SSA to determine my eligibility to sit
for the examination and receive direct payment, and may not otherwise be used except as authorized by law. In the
event that SSA uses information from the criminal background check in whole or in part in making an adverse
decision with regard to my eligibility to sit for the examination or to receive direct payment, I understand that SSA
will provide me a copy of the report on the criminal background check submitted by SSA and a description in writing
of my right to protest the decision to SSA.

I understand that submission of this authorization is voluntary. I also understand that failure to provide the
authorization and information required to conduct a criminal background check will cause SSA to deny my
application.

I understand that copies of this authorization that show my signature are as valid as the original, and that this
authorization is valid for 6 months from the date signed.
CRIMINAL BACKGROUND CHECK INFORMATION
Applicant Last Name: First Name:

Middle Name: Social Security Number:

Date of Birth: Place of Birth:

Sex: Race (Optional):

Please list all of the addresses you have lived at in the last 5 years
Current Address: City/State/Zip Code: From: (mm/dd/yyyy) – Present:

Previous Address: City/State/Zip Code: From: (mm/dd/yyyy) – To: (mm/dd/yyyy)

Previous Address: City/State/Zip Code: From: (mm/dd/yyyy) – To: (mm/dd/yyyy)

Previous Address: City/State/Zip Code: From: (mm/dd/yyyy) – To: (mm/dd/yyyy)

Applicant’s Signature Date: Daytime Phone:

Form SSA-1691 Page 11