Form SSA-1375 Ticket to Work Progress Review Form

Form Approved
OMB No. 0960-0644

Social Security Administration

Progress Review Form
Beneficiary:
Provider:

SSN:

Date:

INSTRUCTIONS: Please inform us of your progress during the timeframe shown below by
completing one of the boxes in Sections A-E below. Check “Yes” or “No” and provide information
on progress with work and earnings, education, or technical training when appropriate to indicate if
you have met the first 12-Month Progress Review requirements. Then sign, date, and return this
form to MAXIMUS using the enclosed postage paid envelope or by fax at 703-683-3289. It is
important that you respond within 30 days of the date on this form. You may retain a copy of this
form for your records.

First 12-Month Progress Review Requirements
Between and :
A. I worked 3 out of 12 months with earnings at or above $670 in each month (Trial
Work Level for 2008).
…Yes
…No
If Yes, STOP here. Sign and date this form and mail or fax back to us.
OR

B. I obtained a GED or High School Diploma.

…Yes

…No

Name of Certifying Agency:_______________________________________________
Agency Address: ________________________________________________________
Date GED or Diploma Earned: _____________________________________________
If Yes, STOP here. Sign and date this form and mail or fax back to us.
OR

C. I completed 60% of a full-time course load for a full academic year in a degree or
certification college program.
…Yes
…No
School Name: __________________________________________________________
School Address: ________________________________________________________
# Credits Completed:______________ # Credits for full course load:______________
Date Completed:________________________________________________________
If Yes, STOP here. Sign and date this form and mail or fax back to us.
GO ON TO THE NEXT PAGE
EIN: <#>
SSN:
SSA-1375 (EF 4/08)

Notice Code: F0001000
Page 1 of 3

Progress Review Form (continued)
Beneficiary:
Provider:

SSN:

Date:

OR

D. I completed 60% of a full-time course load for an academic year in a Technical,
Trade, or Vocational program.
…Yes
…No
School Name: __________________________________________________________
School Address: ________________________________________________________
# Credits Completed:______________ # Credits for full course load:______________
Date Completed:________________________________________________________
If Yes, STOP here. Sign and date this form and mail or fax back to us.
OR

E. I completed a combination of earnings PLUS some college degree or certification
credits or technical, trade, or vocational program credits that together equals or
exceeds 100%.
During this period I earned $__________.
AND
I completed _____ credits of a full-time course load in a degree or college
certification program or in a technical, trade, or vocational program.
School Name: __________________________________________________________
School Address: ________________________________________________________
# Credits for full course load:______________________________________________
Date Completed:________________________________________________________
Sign and date this form and mail or fax back to us.

I understand that if I make, or cause to be made, a representation which I know is false concerning
the requirements of the Ticket to Work and Self-Sufficiency program, I could be punished by fine,
or imprisonment or both.

_____________________________________
Beneficiary Signature

_________________________
Date

Return this form to MAXIMUS within 30 days using the enclosed postage-paid envelope or by
fax at 703-683-3289.
EIN:
SSN:

Notice Code: F0001000
Page 2 of 3

Collection and Use of Information from Your Progress Review Form
Privacy Act Statement
The Social Security Administration is authorized to collect the information on this form under Public Law
106-170 and §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 review of your progress in the Ticket to Work Program. Although responses
to these questions are voluntary, you will not be able to pass the progress review and remain excused
from a medical review unless you answer the questions on this form.
Although the information you give us is almost never used for any other purpose than stated above, 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 programs 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 the 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 us 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.

Paperwork Reduction Act Notice
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 15 minutes to read
the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO
MAXIMUS TICKET TO WORK, PO BOX 1433, ALEXANDRIA, VA 22313, OR FAX TO 703-6833289. 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.

EIN:
SSN:

Notice Code: F0001000
Page 3 of 3