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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)
_
_
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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