Withdrawal of Representative (Do not know if there will be replacement rep)




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Withdrawal of Representative

(Do not know if there will be replacement rep)

Date:

Re: Withdrawal of 1696

Name:


DOB:

SSN:

Social Security Administration

*Local Office Address*


To Whom It May Concern:
This letter serves as notice that I am no longer able to serve as representative for the above referenced individual’s SSI/SSDI. Please remove my name from your records regarding such representation. At this point, I do not know if another representative will be replacing me.
If you have any questions, please do not hesitate to contact me at ( ) . Thank you for your assistance.
Sincerely,

______________________

Signature

______________________

Printed Name

______________________

Address

______________________



Address

______________________

Phone Number

______________________

E-mail address

Withdrawal of Representative

(Include name of next representative)

Date:

Re: Withdrawal of 1696

Name:


DOB:

SSN:

Social Security Administration

*Local Office Address*


To Whom It May Concern:
This letter serves as notice that I am no longer able to serve as representative for the above referenced individual’s SSI/SSDI. Please remove my name from your records regarding such representation. The plan is for______________________ to submit a 1696 to become ____________________’s new representative. We expect that the new form should be submitted by ________________.
If you have any questions, please do not hesitate to contact me at ( ) . Thank you for your assistance.
Sincerely,

______________________

Signature

______________________

Printed Name

______________________

Address

______________________



Address

______________________

Phone Number

______________________

E-mail address


Withdrawal of Representative

(Include name of next representative and attached new 1696)

Date:

Re: Withdrawal of 1696

Name:


DOB:

SSN:

Social Security Administration

*Local Office Address*


To Whom It May Concern:
This letter serves as notice that I am no longer able to serve as representative for the above referenced individual’s SSI/SSDI. Please remove my name from your records regarding such representation. The new representative will be ____________________. A new, completed 1696 is attached.
If you have any questions, please do not hesitate to contact me at ( ) . Thank you for your assistance.
Sincerely,

______________________

Signature

______________________

Printed Name

______________________

Address

______________________



Address

______________________

Phone Number

______________________



E-mail address



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