Form SSA-1391 Employment Network Payment Request Form

Form Approved
OMB No. 0960-0644

SOCIAL SECURITY ADMINISTRATION

EN Payment Request Form
This form may be used to request Evidentiary Payment Requests
(EPRs) or Certification Payment Requests (CPRs)
To ensure prompt and accurate payment to your Employment Network, please complete the following form and
attach any acceptable earnings information required.
I.

Employment Network Information

1.

EN Organization Name: _____________________________________________

2.

EIN Number (Tax ID Number): _______________________________________

3.

Is the financial institution and bank account information provided to the Ticket to Work Operations
Support Manager on the Automated Clearinghouse Payment Enrollment Form (ACH Form) current?
Yes ___ No ___ (if No, please contact MAXIMUS @ 1-866-968-7842 before submitting this request)

Incorrect or outdated information may delay or prevent payment issuance to your Employment Network.

II.

Ticket-holder Information

4.

Ticket-holder’s Name: __________________________________________________

5.

Ticket Number/Social Security Number: ___________________________________

6.

Name of Ticket-holder’s Employer: _______________________________________

7.

Employer’s Address (if available): ________________________________________

8.

Payment Method for this Ticket Assignment
A. Outcome Payment Method ______ B. Milestone-Outcome Payment Method______

III.

Phase 1 - Milestone 1 Earnings Information (Complete only if requesting Phase 1 Milestone 1)

Please choose one of the following options by placing an “X” next to your selection:
___ A. The beneficiary achieved TWL level earnings during the calendar claim month.
___ B. The beneficiary achieved less than TWL , but he/she will achieve TWL earnings within the next 2 months.
___ C. The beneficiary achieved less than TWL earnings and is not expected to achieve TWL earnings
within the next 2 months.

Form SSA-1391 (xx-xxxx)

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IV.

Payment Request Details

9.

Payment Request Type
_______ A. Evidentiary Payment Request – (Complete Section V)
_______ B. Certification Payment Request – (Complete Sections VI and VII)

10.

Claim month(s) and year(s) for this payment request:
____________________________________________________________
____________________________________________________________

V.

Evidentiary Earnings Information

11.

Type of earnings documentation submitted: (these items must be included with this form)
___ Pay slips
___ Employer prepared and signed employee earnings statement
___ Records from Third Party Source containing monthly wage information
____The Work Number ____Other

VI.

Certification Payment Request Details

12.

Type of Certification Information (Choose one):
____ Recent contact with beneficiary/employer (please circle “beneficiary” or “employer”)
____ Attached Earnings Inquiry Request (EIR) response received from MAXIMUS
____ Attached information containing data from the National Directory of New Hires (NDNH)
____ Attached Self Employment Income (SEI) Form (if beneficiary is self-employed)

13.

Recent Contact Details (complete only if you selected “recent contact” on item 12):
Type of contact (phone call, email, etc): ________________________________
Date of contact: ______________________
Description of information you learned from contact regarding level of earnings:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Form SSA-1391 (xx-xxxx)

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VII.

Repayment Agreement (signature required):
I declare under penalty of perjury that I have examined all the information on this
form, and on any accompanying statements or forms, and it is true and correct to
the best of my knowledge. I understand that anyone who knowingly gives a false or
misleading statement about a material fact in this information, or causes someone
else to do so, commits a crime and may be sent to prison, or may face other
penalties, or both.
By signing below, you as the EN agree to repay any payments received (or allow the amount to
be deducted from future payments) if it is determined at a later date that you were not entitled to
payment.
___________________________________________________________________
Signature
Date

VIII.

Contact Information for the Employment Network Representative Submitting this Request
Print Name: ________________________________________________________
Phone Number: ____________________ FAX: ______________________
Email: ________________________________________________________

Ticket to Work and Self-Sufficiency Program
Payment Request
PO Box 1433
Alexandria, VA 22313-1433

Form SSA-1391 (xx-xxxx)

FAX: 703-683-3289

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Privacy Act Statement
Collection and Use of Personal Information

Section 1148, of the Social Security Act, as amended, authorizes us to collect this information. The
information is needed to permit the Social Security Administration (SSA) to verify eligibility for
payment. The information you furnish on this form is voluntary. However, failure to provide all or part
of the information requested on this form could prevent you from receiving payment.
We rarely use the information you supply for any purpose other than verifying eligibility for payment.
However, we may use it for the administration and integrity of Social Security programs. We may also
disclose information to another person or to another agency in accordance with approved routine uses,
which include but are not limited to: (1) to enable a third party or an agency to assist Social Security in
establishing rights to Social Security benefits and/or coverage; (2) to comply with Federal laws requiring
the release of information from Social Security records (e.g., to the Government Accountability Office
and Department of Veteran Affairs); (3) to make determinations for eligibility in similar health and
income maintenance programs at the Federal, State, and local level; (4) to State agencies or Employment
Networks having an approved business arrangement with SSA to perform vocational rehabilitation
services for disability beneficiaries and recipients; and (5) to facilitate statistical research, audit or
investigative activities necessary to assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, state or local government agencies.
Information from these matching programs can be used to establish or verify a person’s eligibility for
Federally funded and administered benefit programs and for repayment of payments or delinquent debts
under these programs.
A complete list of routine uses for this information is available in Systems of Record Notices 60-0295
and 60-0300. The notices, additional information regarding this form, and information regarding our
programs and systems, are available on-line at www.socialsecurity.gov or at your local Social Security
office.

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.
5 minutes to read the instructions, gather the facts, and answer the
We estimate that it will take about XX
questions. SEND THE COMPLETED FORM TO MAXIMUS TICKET TO WORK, PO BOX
1433, ALEXANDRIA, VA 22313, OR FAX TO 703-683-3289.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.

Form SSA-1391 (xx-xxxx)

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