Identifying Information for Possible Direct Payment of Authorized Fees (SSA 1695 Form)

SSA FORMS

Form Description

SSA-1695 Identifying Information for Possible Direct Payment of Authorized Fees (SSA 1695 form) (9-06 version) 1 SSA 61 Request for Review by a Federal Reviewing Official 2 SSA 3373-BK Disability Report Adult - SSA 3373 BK- 10 pages 3 SSA 3380-BK FUNCTION REPORT - ADULT - THIRD PARTY Form SSA-3380-BK 4 SSA-3368-BK DISABILITY REPORT—ADULT— Form SSA 3368 BK 5 SSA-3369-BK Work History Report - SSA 3369 BI 6 SSA-3820-BK Disability Report - Child - SSA 3820 BK 7 SSA 16-BK Application for Disability Insurance Benefits 8 SSA 8000-BK (also known as Application for Supplemental Security Income (10 pages; revised to 12/06 version and approved by SSA) SSA 8001-BK) (formerly 8001- 9 FS) SSA 2506-BK Psychiatric Review Technique SSA 2506 BK 10 SSA 4734-BK Physical Residual Functional Capacity Assessment SSA 4734 BK 11 SSA-4734-F4-SUP MENTAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT 12 SSA 1020 Application for Help with Medicare Prescription Drug Plan Costs, SSA-1020 13 SSA-3 Marriage Certification - 2 pages 14 SSA-21 Supplement to Claim of Person Outside the 15 United States 16 SSA 131 EMPLOYER REPORT OF SPECIAL WAGE PAYMENTS 17 SSA 150 MODIFIED BENEFIT FORMULA QUESTIONNAIRE 18 SSA-308 Modified Benefits Formula Questionnaire, Foreign Pension 19 SSA-521 Request for Withdrawal of Application 20 SSA-545 Plan for Achieving Self-Support 21 SSA-546 Worker's Compensation/Public Disability Questionnaire 22 SSA 671 Railroad Employment Questionnaire 23 SSA-723 Statement Regarding the Inferred Death of an Individual 24 SSA-781 Certificate of Responsibility for Welfare and Care of Child 25 SSA-782 Form has been replaced by form SSA-3441-BK 26 SSA 783 Statement Regarding Contributions 27 SSA 788 STATEMENT OF CARE AND RESPONSIBILITY FOR BENEFICIARY 28 SSA-789 Request for Reconsideration - Disability Cessation 29 SSA 795 STATEMENT OF CLAIMANT OR OTHER PERSON 30 SS-5 Application for a Social Security Card 31 SS-5-FS Application for a Social Security Card 32 SSA 820 Work Activity Report (Self-Employed Person) 4 pages 33 SSA 831 Work Activity Report (Employee) - 8 pages 34 SSA-827 Authorization to Disclose Information to SSA 35 SSA 1199A Direct Deposit Sign-Up Form (SF-1199A) 36 1372-BK STUDENT'S STATEMENT REGARDING SCHOOL ATTENDANCE (8 pages) 37 SSA 2512 Pre-1957 Military Service - Federal Benefit Questionnaire (2 pages) 38 SSA 2519 Child Relationship Statement 39 SSA-2000 Application for Special Benefits for World War II Veterans 40 SSA-1696 Appointment of Representative 41 HA-4631, 4632, & 4633 Combines 4631, 4632, and 4633 into one convenient document! 42 HA-4633 Claiman's Work Bankgroud - SSA 4633 & HA 4633 43 HA-4632 Claimant's Medications - SSA 4632 & HA 4632 44 SSA 3369 BK WORK HISTORY REPORT-Form SSA-3369-BK (10 pages) 45 SSA 3441-BK (SSA3441) DISABILITY REPORT - APPEAL - Form SSA-3441-BK (10 pages) 46 HA-4631 Claimant's Recent Medical Treatment - SSA 4631 & HA 4631 47 SSA 538-F6 Childhood Disability Evaluation Report (6 pages) 48 SSA 3820 Disability Report - Child Form SSA-3820-BK (14 pages) 49 SSA 3881 QUESTIONNAIRE FOR CHILDREN CLAIMING SSI BENEFITS (8 pages) 50 SSA 3885 Government Pension Questionnaire 51 SSA 4162 Child care Dropout Questionnaire (2 pages) 52 HA-4486 Form has been replaced by form SSA-3441-BK 53 SSA 4184 Self-Employment - Corporate Officer Questionnaire 54 SSA TEACHER QUESTIONNAIRE (10 pages) 55 5665 56 SSA 5666 REQUEST FOR ADMINISTRATIVE INFORMATION (2 pages) 57 SSA 7008 REQUEST FOR CORRECTION OF EARNINGS RECORD (2 pages) 58 SSA 7014 Partnership Questionnaire 59 HA-4633 Claimant's Work Background 60 SSA 7156 Farm Self-Employment Questionnaire 61 SSA 7157 Farm Arrangement Questionnaire 62 SSA 7163 QUESTIONNAIRE ABOUT EMPLOYMENT OR SELF-EMPLOYMENT OUTSIDE THE UNITED STATES (2 pages) 63 SSA 7163A SUPPLEMENTAL STATEMENT REGARDING FARMING ACTIVITIES OF PERSON LIVING OUTSIDE THE U.S.A. 64 SSA 7050 REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION (4 pages) 65 SSA-3288 Consent for Release of Information 66 SSA-437 Discrimination Complaint 67 SSA-131 Employer Report of Special Wage Payments 68 HA-539 Notice Regarding Substitution of Party Upon Death 69 SSA-1560 Petition to Obtain Approval of a Fee for Representing a Claimant 70 SSA-3441-BK Disability Report - Appeal 71 HA-501 Request for Hearing by Administrative Law Judge 72 SSA-561-U2 Request for Reconsideration 73 HA-520 Request for Review of Decision/Order of ALJ 74 SSA-632 Request for Waiver of Overpayment Recovery 75 SSA-7004 Request for Social Security Statement 76 SSA-7004-SP Solicitud de Declaración de Ganancias 77 SS-5-SP Solicitud Para una Tarjeta de Seguro Social 78 HA-4608 Waiver of Your Right to Personal Appearance Before an ALJ 79 HA-510 Waiver of Written Notice of Hearing 80 SSA-783 Statement Regarding Contributions 81 SSA-788 Statement of Care and Responsibility for Beneficiary 82 SSA-795 Statement of Claimant or Other Persons 83 SSA-820 Work Activity Report (Self-Employed) 84 SSA-821 Work Activity Report, Employee 85 SSA-1372 Student's Statement Regarding School Attendance 86 SSA-1724 Claim for Amounts Due in Case of a Deceased Beneficiary 87 SSA-2512 Pre-1957 Military Service Federal Benefit Questionnaire 88 SSA-2519 Child Relationship Statement 89 SSA-3820 Disability Report, Child 90 SSA-3369 Work History Report 91 SSA-3885 Government Pension Questionnaire 92 SSA-4162 Child Care Dropout Questionnaire 93 SSA-4184 Self Employment Corporate Officer Questionnaire 94 SSA-4395 Application for Access to SSA Headquarters Facilities 95 SSA-7008 Request for Correction of Earnings Record 96 SSA-7050 Request for Social Security Information 97 SSA-7104 Partnership Questionnaire 98 SSA-7156 Farm Self Employment Questionnaire 99 SSA-7157 Farm Arrangement Questionnaire 100 SSA-7163 Questionnaire About Employment or Self Employment Outside the 101 US 102 SSA-7163A Statement Regarding Farming Activities of Persons Living Outside US 103 SSA-150 Modified Benefits Formula Questionnaire 104 SSA-671 Railroad Employment Questionnaire 105 SSA 6559 Transmitter Report and Summary of Magnetic Media 106 SSA 6559-A Continuation Sheet for Form 6559 107 SF-1199A Direct Deposit Sign-Up Form 108 SSA-5665-BK Teacher Questionnaire 109 SSA-5666 Request for Administrative Information 110 SSA-3881 Questionnaire for Children Claiming SSI Benefits 111 SSA 8001 BK (also known as Application for Suplemental Security Income (new form 12/06) 10 pages & approved by SSA SSA 8001-BK; was SSA 112 8001BK-FS)