Form SSA-1375 Ticket to Work Progress Review Form

Timely Progress Requirements to Pass
Each 12-month Timely Progress Review
1st 12Month
Review:

Complete 3 months of work at Trial Work Level amount (refer to Form for amount),
OR complete GED or high school diploma, OR complete 60% of a full-time course
load for an academic year in a college or technical, trade or vocational training
program, OR complete a combination of this work and education requirement.

2nd 12Month
Review:

Complete 6 months of work at Trial Work Level amounts (refer to Form for amount),
OR complete 75% of a full-time course load for an academic year in a college or
technical/trade/vocational training program, OR complete a combination of this
work and education requirement.

3rd 12Month
Review:

Complete 9 months of work at Substantial Gainful Activity amount (refer to Form
for amount), OR complete an additional full-time academic year of study, OR complete a 2-year or 4-year college program, OR complete a 2-year technical, trade or
vocational training program, OR complete a combination of this work and education requirement.

4th 12Month
Review:

Complete 9 months of work at SGA amount (refer to Form for amount), OR complete
an additional academic year of full-time study, OR complete a combination of this
work and education requirement

5th 12
Month
Review:

Complete 6 months of work at SGA amount (refer to Form for amount) with no SSDI
and/or SSI cash benefits in months worked,OR complete an additional academic
year of full-time study, OR complete a 4-year degree program.

6th 12
Month
Review:

Complete 6 months of work at SGA amount (refer to Form for amount) with no
SSDI and/ or SSI cash benefits in months worked, OR complete a 4-year degree
program.

7th 12
Month
Review:

Complete 6 months of work at SGA amount (refer to Form for amount) with no
SSDI and/or SSI cash benefits in months worked. *

* The guidelines for any subsequent 12-month Progress Review are the same as for the 7th 12-month
Progress Review

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OMB No. 0960-0644

Progress Review Form
NAME LEANN MEAUX
Beneficiary: AMBER
Provider: LOUISIANA REHABILITATION SERVICES

Date: 03/21/2012

INSTRUCTIONS: Please inform us of your progress during the timeframe shown below by completing one or more of the boxes in Sections A-G 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 Ticket to Work using the enclosed postage paid envelope or by fax at
703-893-4020. 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 March 2011 and February 2012
A. I worked 3 out of 12 months with gross earnings at or above $ 648* in each month during
the 12 month review period.
❑ Yes
❑ No
OR
B. I obtained a GED or high school diploma during the 12 month review period.
❑ Yes
❑ No
Name of School or Agency
Providing GED:
Month and Year of Completion:

GO TO THE NEXT PAGE
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Progress Review Form (continued)
Beneficiary: NAME
AMBER LEANN MEAUX
Provider: LOUISIANA REHABILITATION SERVICES

Date: 03/21/2012

Between March 2011 and February 2012
OR
C. I completed a 2-year or 4-year college program during the 12 month review period.
❑ Yes
❑ No
School Name:
Month and Year of Completion:

OR
D. I completed a technical, trade, or vocational program during the 12 month review period.
❑ Yes
❑ No
School Name:
Type of Program Completed:
Month and Year of Completion:
OR
E. I completed some credits in a college program during the 12 month review period.
❑ Yes
❑ No
Number of Credits Completed
and number of credits needed to complete
program
School Name:

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Progress Review Form (continued)
Beneficiary: NAME
AMBER LEANN MEAUX
Provider: LOUISIANA REHABILITATION SERVICES

Date: 03/21/2012

Between March 2011 and February 2012
OR
F. I completed some credits/hours/courses in a technical, trade, or vocational program during
the 12 month review period.
❑ Yes
❑ No
Number of Credits/Hours/Courses Completed
and number of credits/hours/courses needed to complete program
School Name:
Type of Program:
OR
G. I completed a combination of earnings PLUS some education or training credits/hours/courses.
During this period, I worked
out of 12 months with gross earnings at or above $ 648* in
each month.
I completed
credits/hours/courses in a college program or in a technical, trade, or vocational
program and the number of credits/hours/courses needed to complete program
School Name:
Sign and date this form and mail or fax back to us.
* Amount represents 10% less than the Trial Work Level amount or the Substantial Gainful Activity
amount for the progress review period.
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 Ticket to Work within 30 days using the enclosed postage-paid envelope or by
fax at 703-893-4020.

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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 TICKET TO WORK, PO BOX 1433, ALEXANDRIA, VA 22313, OR
FAX TO 703-893-4020. 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.
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