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SSA-1695

Identifying Information For Possible Direct Payment Of Authorized Fees

Download and Print the SSA-1695

Request may not be processed if the form is incomplete or illegible.

Information About the Claimant

First Name - Middle Name - Last Name - Suffix

Social Security Number
_
_
Wage Earner's Name (if different than above)

Wage Earner's Social Security Number (if different)
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_
Type of Benefits

Title II (RSDI)

Title XVI (SSI)

Information about You, the Representative

Name

Social Security Number
_
_
P.O. Box, Street, Apt.,or Suite No. - City - State - ZIP Code or Postal Zone - Country

And much more...

 
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