I Social Security Administration Please read the back of the last copy before you complete this form. Name Claimant Print or Type Wage Earner if Different Form Approved OMB No. 0960-0527 APPOINTMENT OF REPRESENTATIVE Part I I appoint this person Name and Address to act as my representative in connection with my claim s or asserted right s under Title 11 RSDI Title XVI SSI Title IV FMSHA Black Lung Medicare Coverage SVB This person may entirely in my place make any request or give any notice...