Social security sample fee agreement

This service allows you to electronically complete the Fee Agreement for Representation Before the Social Security Administration (Form SSA-1693). You, the claimant, and up to five additional representatives may sign the form and submit it to us electronically. Do not use this electronic form if there are more than six representatives who will be seeking a fee for services provided on this claim. Before you begin, you will need the following information:

• Your valid email address.
• The claimant's valid email address.
• The valid email addresses and up to five additional representatives who will be signing this fee agreement.

IMPORTANT: We will not receive or process the form until you, the claimant, and any additional representative(s) whose email address(es) you provide have completed the steps below and electronically signed the form.

Step One. You, the Appointed Representative, must complete your designated sections of the form, sign the form electronically, and select “Click to Sign” to submit the form.

Before beginning the form, you will first enter and confirm the email addresses for you, the claimant, and up to five additional representative(s) into the application online. We will refer to these individuals as “all parties” in these instructions.

You will also create a password that will be required for all parties to access the form. You should provide the password to the other parties by phone, in person, or SMS text message (standard message and data rates may apply). If you are unable to contact the other parties by phone, in person, or by text, then you may send the password in a separate email message. You will not be able to reset the password. If it is lost or forgotten, you will have to restart the process.

You will receive an email from adobesign@adobesign.com containing a link and instructions on how to access the form.

NOTE: After you submit the form, all other parties will receive an email from adobesign@adobesign.com containing a link and instructions for accessing and signing the form. The form must be completed by all parties within ten (10) calendar days after you initiate the process online (i.e., when you enter all of the parties’ email addresses in order to receive an email with a link to the form). You should inform all parties about the importance of taking action upon receipt of the email. If all parties do not complete, sign, and submit the form within ten (10) calendar days, you will need to restart the process.

Step Two. After you have completed Step One, the remaining parties will receive an email with a link to access and review the partially completed form, complete their designated sections, sign the form electronically, and select “Click to Sign” to submit the form. There is no specific order required for the other parties to complete the form, but all must electronically sign and submit it within the 10-day period.

After successful submission of the form by all parties, adobesign@adobesign.com will send an email to all parties with a link to the completed form. This will allow you to save a copy for your records using the pre-established password.

PLEASE NOTE:

• This website is most compatible with the following browsers: Microsoft Edge and Google Chrome.
• When accessing the form, the system will end your session after 60 minutes of inactivity. Use the link in your email and your pre-established password to continue working on your form.
• A daily email reminder will be sent to the necessary parties until the form has been submitted or until the time expires (i.e., ten (10) days after initiation).
• You, the Appointed Representative, will have to restart the process if any of the following situations apply:
  • The password is lost or forgotten. The password cannot be reset.
  • You (or the other parties) do not receive an email notification within a few minutes of your online submission. Be sure to check your junk folder.
  • All parties do not electronically sign and submit the form within ten (10) calendar days.

  Sections 206 and 1631(d) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may affect the amount of fees authorized for services rendered before us.

  We will use the information you provide to authorize fees for services rendered to the claimant named on the form. We may also share your information for the following purposes, called routine uses:

  • To a claimant’s representative to the extent necessary to dispose of a fee petition or fee agreement; except for pre-decisional deliberative documents, such as analyses and recommendations prepared for the decision-maker;
  • To contractors and other Federal agencies, as necessary, for the purpose of assisting us in the efficient administration of our programs; and
  • To the Internal Revenue Service and to State and local government tax agencies in response to inquiries regarding receipt of fees we paid directly starting in calendar year 2007.

  In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.