Form SSA-1370 Ticket to Work Individual Work Plan

Ticket to Work Individual Work Plan (IWP)
Statement of Understanding: I choose to participate in the Ticket to Work Program with the
employment network (EN) named below. I understand that my EN will provide me with
employment support to find and keep a job, increase my earnings or run my own business. If
possible, I plan to increase my earnings to support myself. I understand that I can change this
plan with my EN from time to time to meet my current needs.
EN Name:
DUNS Number:
Telephone:

Email:

Address:

My Name:
SSN:
Telephone:

Email:

Address:

Alternate Contact Name:
Telephone:

Email:

Address:

Alternate Contact Name:
Telephone:

Email:

Address:

Alternate Contact Name:
Telephone:

Email:

Address:

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1. My Vocational Goal and Expected Monthly Earnings
Short Term Vocational Goal (in the next 3 to 12 mos.):

Expected Monthly Earnings (in the next 3 to 12 mos.):

Long Term Vocational Goal (in the next 3 to 5 years):

Expected Monthly Earnings (in the next 3 to 5 years):

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2. The Supports and Services the EN Agreed to Provide to Help
Me Reach My Vocational Goal
My EN and I have agreed upon the supports/services checked or written below. Below we also
explain the steps the two of us agreed to take to help me reach my vocational goal. This
includes any referrals my EN agreed to make to help me get services.



Career counseling and guidance (at a minimum, required during IWP development)
Note: On the last page, EN must certify to providing career counseling.






Job search or placement services (required, if not working)





Job coaching/training





Job accommodation planning





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

Continuing employment supports (at a minimum, quarterly contact by EN to assess
needs)






Other (please explain below)





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3. My Recent Work History (Check all that apply)
I am currently working.
I had no earnings in the last 18 months.
I had some earnings in the last 18 months.
None of my earnings were in the last 6 months.
Some of my earnings were in the last 6 months.
(If you had earnings in the last 6 to 18 months, please describe those earnings in the following
chart. List your employer first.)
Employer

Start Date

End Date

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Wage Per
Hour

Hours Worked
Per Week

4. Conditions Related to the Success of my IWP
•

I will inform my EN of changes in my contact information.

•

My EN will contact me as needed to share information and determine any unmet needs
(at least quarterly).

•

I will inform my EN of my earnings.

•

While I am working, my EN will offer and provide me with ongoing employment support
to help me keep working or refer me to others who can help me keep working.

My EN and I have agreed to the other conditions described below (If there are no other
conditions, please state that):

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RIGHTS & REMEDIES
I understand that I have the following rights under the Ticket to Work Program. As my EN,
, you:
1) May not request or accept any compensation from me for the costs of services and supports
provided to me as an EN.
2) May change this IWP, as long as we both agree. Any change to this IWP must be made in
writing.
3) Will provide or help me to obtain ongoing employment support, as necessary, designed to
help me keep my job.
4) May unassign my Ticket at any time if either of us are not satisfied for any reason.
5) Explained its internal resolution process. If we are unable to resolve a dispute, another
process is available to me through the Ticket Call Center at 1-866-968-7842.
6) Provided me with the phone number of the State Protection and Advocacy Program where I
can receive free services.
The phone number is
7) Informed me of the annual progress reviews and the Timely Progress Review guidelines.
8) Will keep my personal information, including my Social Security number and information
about my disability, private and confidential.
9) Will use only qualified employees and/or providers to provide services to me.
10) Will provide me with a copy of this IWP and any changes in an accessible format.

I declare under penalty of perjury that I have examined all the information on the form
and any accompanying statements or forms, and it is true and correct to the best of my
knowledge.
By signing below, I agree to the terms of this IWP and give permission for the EN named in this
IWP to contact employers on my behalf to verify or obtain evidence of work or earnings.

Beneficiary’s Signature

Date

EN Representative’s Signature

Date

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FOR EN’S COMPLETION
Record of Career Counseling Provided During IWP Development

(Date of Counseling)

(Duration of Counseling Session)

(Date of Counseling)

(Duration of Counseling Session)

(Name of Counselor)

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