Form SSA-1391 Employment Network Payment Request Form

EN Payment Request Form
Use this form 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

EN Organization Name:
DUNS Number:
Is the financial institution and bank account information provided in your Central
Contractor Registration (CCR) current?

Yes

No

If No, please visit www.ccr.gov and update your CCR registration with your correct bank account
information before submitting this request. Incorrect or outdated information in CCR will prevent
payment issuance to your Employment Network.

II.

Ticket Holder Information

Ticket Holder’s Name:
Ticket Number/Social Security Number:
Name of Ticket Holder’s Employer:
Employer’s Address (if available):
Payment Method for this Ticket Assignment:
Outcome Payment Method

III.

Milestone-Outcome Payment Method

Phase I Milestone 1 Earnings Information

Select one option only if requesting a Phase I Milestone 1 payment.
The beneficiary achieved Trial Work Level (TWL) earnings during the calendar claim month
(TWL = $720 for 2010, 2011, and 2012; $700 for 2009; $670 for 2008).
The beneficiary achieved less than TWL, but expects to achieve TWL earnings within the next 2
months.
The beneficiary achieved less than TWL earnings and is not expected to achieve TWL earnings
within the next 2 months.

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

FAX: 703-893-4020

-1F-PMT-7013 EN Payment Request Form V04

IV.

Payment Request Details

Payment Request Type
Evidentiary Payment Request (Complete Section VI)
Certification Payment Request (Complete Sections VII and VIII)
Claim month(s) and year(s) for this payment request:

V.

EN Services Details

If requesting Phase I Milestone 1, describe in detail the services provided since the ticket assignment
date. If requesting Phase I Milestone 2 or 3, describe in detail the services provided since the last
milestone payment month.
Milestone
Payment

Date of Services

Description of Services

PI M1
PI M2
PI M3
Note: When requesting the following payments, complete and attach the EN Services Certification
Statement: Phase I Milestone 4, Phase II Milestone 11, Outcome 11 or Outcome 22.

VI.

Evidentiary Earnings Information

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

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

FAX: 703-893-4020

-2F-PMT-7013 EN Payment Request Form V04

VII.

Certification Payment Request Details

Type of Certification Information (choose one):
Recent contact with beneficiary
Recent contact with 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)
Recent Contact Details (complete only if you selected Recent Contact above)
Type of contact (phone call, email, etc.):
Date of contact:
Description of information you learned from contact regarding level of earnings:

VIII. Repayment Agreement
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:

IX.

Date:

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

FAX: 703-893-4020

-3F-PMT-7013 EN Payment Request Form V04