Advance Letter to Beneficiary

OMB Control No. 0960-0526

Expiration Date: June 2012

EurekaFacts Ticket to Work

Street Address

City, State Zip

Insert Date

Dear (Insert Name),

Social Security is conducting a Customer Satisfaction survey of individuals in the Ticket to Work program who are assigned to an Employment Network (EN).

Within the next week, you will receive a survey in the mail asking how satisfied you are with your EN, (Insert name of EN). Your name will not be on the survey and your EN will not see your personal responses. Social Security will use all responses to prepare a new EN report card to let future beneficiaries know how satisfied other beneficiaries are with a particular EN.

The EN Customer Satisfaction Survey will take about 10 minutes to read and complete. You may choose to complete the survey either on the internet at a secure website, or by mail using the paper survey form. (You do not need to do both.) We will provide a postage paid envelope in which you may return the paper survey, and a unique password to use if you choose to complete the online survey instead.

We hope you will take part in this survey. Your opinions are very important because they will help us improve services to you and others in the Ticket to Work program. Thank you in advance for your help.

If you have any questions about this survey, you may contact EurekaFacts at XXX-XXX-XXXX. EurekaFacts is supporting Social Security’s survey for the Ticket to Work program.

Sincerely,

EurekaFacts – Ticket to Work