Current SSA-1365

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Form Approved
OMB No. 0960-0641

STATE AGENCY TICKET ASSIGNMENT FORM
TICKET TO WORK AND SELF·SUFFICIENCY PROGRAM
Instructions - This form must be completed to record that a beneficiary who is a ticket holder
has decided to assign the ticket to a State Vocational Rehabilitation (VR) Agency. The form
must be completed by both the State VR agency representative and the ticket holder or, as
appropriate. the ticket holder's represenlative. The Slate VR agency will subm~ this form in
lieu of submitting the Individualized Plan for Employment. The ticket holder or hislher
representative, as appropriate must sign this form to confirm the decision to assign the ticket
to the State VR agency. The Slate VR agency will e~her send or fax the completed and
signed form to:
MAXIMUS Ticket to Work
ATTN: Ticket Assignment
P.O. Box 25105
Alexandria, VA 22313

Mail·

Fax • 703-683-3289

A. To be Completed by State VR Agency (after verffylng the beneficiary has a tIcket
which may be 888lgned 0 the State VR agency)
1. Enter the Stale VR Agency's name
Enter the State VR Agency's Employer Identification Number (EIN)

3. Ticket Holder Number (This Is the Socia/security Number on
the ticket with the TW suffix.)
_ _ _ _ _ _ TW _ _

2. T1c::ket Hokler's Name (Last, First, MWfe Initial)

4. (a) What vocational objective or employment outcome Is outlined In the ticket holder's Individualized Plan for Employment?

(b) What Is the expected type of job? (Check one EEOC classification below):

o
o
o
o

ExecutlveIManagerial
Professional

sales
TectmicalfParaprofesslonal

0
0
0
0

5. (a1 Date the Individualized Plan for Employment was
signed by ticket holder or hiSiller representative

SkJlled Craft

o

Laborer

5ecretariaVOfficeIClerical
Service Worker
Operative
5. (b) Date the Individualized Plan for Employment was
Sll1led by the State VR agency counselor
(month, day, year)

(month. day. yesr)

6. In the Indilltduallzed Plan for Employment. date established lor meeting the vocational objective chosen (month. year)
7. What SSA Payment system is the State VR agency selecting with respect to this ticket holder?
(PIMI8 an X In the appropriate box.)

o
o

Cost Reimbursement Payment System
State VR agency's employment netv.lor1< payment system of recOld
(If this option Is selected, submit Foml SSA-1366, 'State Vocational Rehabilitation Tlck.et to Work Information Sheet"
or equivalent informatiofl with this SSA-1365)

B. To be completed by the ticket holder or ticket holder's representative
Cl'Iec:k the appropriate box and sign your name in the space provided below.

o
o

I am the ticket holder to whom the Information on this form applies.
I am the representative of the ticket hOlder to whom the Information on this form applies and am acting on hlslher behalf.

I understand that ont* my tJckell. aulgned to the 51ate VR agency. I have the right to retrieve my ticket for any r&8aon.
I acknowledge that the Information contained on this fonn relating to the ticket holder III correct, and that I do willingly
agree to assign my ticket to the Stele VR agency shown above.
I understand that If I make, or cause to be made, a representation which I know III faille concemlng the requirements of
the Tlckel to Work and self-Sufficiency program, I could be punished by a fine. or Imprisonment. or both.

Ticket Holder or Representative Signature

State VR Agency Representative Signature

0."

Date

Form SSA·1365 110-20011

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Collection and Use of Information from Your Ticket Assignment Form
Privacy Act Statement
The Social Security Administration is authorized to collect the information on this form
under Public Law 106-170 and section 1148 of the Social Security Act. While
furnishing the information on this form is voluntary, failure to provide all or part of the
information on this form to the Social Security Administration will prevent assignment
of your Ticket to Work to the provider of services chosen by you. The information
provided on this form will allow the Social Security Administration to monitor the
progress of a participant in the Ticket to Work and Self-Sufficiency Program.
Although the information you furnish on this form is almost never used for any other
purposes than stated in the foregoing, there is a possibility that for the administration
of the Social Security programs or for the administration of programs requiring
coordination with the Social Security Administration, information may be disclosed to
another person or to another government agency as follows: (1) to another Federal,
State, or local government agency for determining eligibility for a government benefit
or program; (2) to a Congressional office requesting information on behalf of the
program participant; (3) to a third party for the performance of research and statistical
activities; and (4) to the Department of Justice for use in representing the Federal
Government.
The information you provide may also be used without your consent in automated
matching programs. These matching program are computer comparisons of Social
Security Administration records with records kept by other Federal agencies or State
and local government agencies. Information from these matching programs can be
used to establish or verify a person's eligibility for federally funded or administered
benefit programs and for repayment of payments or delinquent debts under these
programs.
We may also use this information you give us when we match records by computer.
Matching programs compare our records with those of other Federal, State, or local
government agencies. Many agencies may use matching programs to find or prove
that a person qualifies for benefits paid by the Federal government. The law allows us
to do this even if you do not agree to it.
~

Explanations about these and other reasons why information you provide may be used
or given out are available in Social Security offices. If you want to learn more about
this, contact any Social Security office.

~"

€

rue, .st 6Paperwork
r t:. r\ Reduction
f\ +f,.."',<,- J
Act Notice

We are required by law !V'"ti!Y'yOU that th~nfom;ation collecJjPn1s in accordance
with the clearance r<;9uirements of 44 U.S-C. §3507, as a;:perilJed by Section 2 of the
Paperwork Reduction Act of 1995. We may not conduct or sponsor, and YOJ are not
required to respond to, a collection of informatiOn)Jnress it displays a va!jd Office of
Management and Budget control number. W)l-estimate that it will take"you about
3 minutes to comple!e1his form. This in9J-'des the time it takeS)e1ead the
instructions, gatpef'ihe necessary fac)lr.'and answer the ques11Ons.
·u.s. GlMImtnenl Printing 0IIiclI; 2002 -

491.till91603O:l

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 3
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.