Form SSA-1401 Employment Network Split Payment Request Form

Social Security Administration

Form Approved
OMB NO: 0960-0644

Employment Network Split Payment Request Form
Beneficiary SSN:

Employment Networks
Current EN:
DUNS:
Ticket Assignment Date:
Contact Name:
Phone:

Prior EN:
DUNS:
Ticket Assignment Date:
Contact Name:
Phone:

Prior EN:
DUNS:
Ticket Assignment Date:
Contact Name:
Phone:

Prior EN:
DUNS:
Ticket Assignment Date:
Contact Name:
Phone:

PROPOSED SPLIT PAYMENT
Please review the options below and indicate which split payment method would be
most applicable to the ENs requesting payment.[PLEASE NOTE: This applies for the duration of the
beneficiary’s ticket]

I WANT MAXIMUS TO MAKE THE SPLIT PAYMENT DETERMINATION
Please check the box below to indicate that
you would like MAXIMUS to determine the split payment percentages

I WANT MAXIMUS TO USE THE AGREED UPON SPLIT PAYENT ALLOCATION
CHART BELOW
In the event there is two or more ENs involved in the split payment process for a beneficiary, the
percentage must be in denominations of 10 and the total for each payment request types should equal
to 100%. Remember the split will apply to all payment requests for the duration of the ticket.
Please refer to examples outlined below for assistance in filling out the chart.
Example#1- Title II or Concurrent beneficiary-- Two ENs involved
Payment
Types

Payment
requests

Current En
Name: ABC, Inc

Phase One
Milestones
Phase Two
Milestones
Outcome
Payments

P1M1-4

80%

Prior En#2
Name: 123
Company
20%

P2M1-11

90%

10%

O 1-36

100%

0%

Form SSA-1401 (05-2011)

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Prior EN#3
Name:

Prior EN#4
Name:

Social Security Administration

Form Approved
OMB NO: 0960-0644

Example#2- Title 16 beneficiary/Three ENs involved
Payment
Types

Payment
requests

Current En
Name: ABC, Inc
30%

Prior En#2
Name: 123
Company
10%

Prior EN#3
Name: XYZ,
Inc
60%

Phase One
Milestones
Phase Two
Milestones
Outcome
Payments

P1M1-4
P2M1-18

40%

10%

50%

O 1-10
O 11-60

50%
70%

0%
0%

50%
30%

Prior EN#4
Name:

SPLIT PAYMENT CHART FOR TWO OR MORE ENs
Following the examples above please fill out the chart below:
PAYMENT
TYPES

PAYMENT Current EN
REQUESTS
Name:

Prior EN#1
Name:

Prior EN#2
Name:

Prior EN#3
Name:

Prior EN#4
Name:

Phase One
Milestones

Phase Two
Milestones

Outcome
Payments

We have discussed the services provided to the Ticket holder and agree to split the EN payments as
requested above.

EN Signature:
EN Signature:
EN Signature:
EN Signature:

Date:
Date:
Date:
Date:

NOTE: MAXIMUS will make the actual determination regarding the allocation of payments to EN’s requesting payment for the same
outcome, milestone, or reconciliation payment under its elected payment system.

Form SSA-1401 (05-2011)

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Social Security Administration

Form Approved
OMB NO: 0960-0644

Privacy Act Statement
Collection and Use of Personal Information
Public Law 106-170 and Section 1148 of the Social Security Act, as amended,
authorize us to collect this information. The information you provide will be used to
document requirements towards achieving your employment goal. The information
you furnish on this form is voluntary. However, failure to provide the requested
information could prevent you from pursuing your employment goal under the Ticket
to Work program.
We rarely use the information you supply for any purpose other than for the Ticket to
Work program. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose information to another person or to another
agency in accordance with approved routine uses, which include but are not limited to
the following:
1. To enable a third party or an agency to assist Social Security in establishing rights
to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department of
Veterans' Affairs);
3. To State agencies or Employment Networks having an approved business
arrangement with Social Security to perform vocational rehabilitation services for
disability beneficiaries and recipients; and
4. To facilitate audit or investigative activities necessary to assure the integrity of
Social Security programs.
We may also use the information you provide in computer matching programs.
Matching programs compare our records with records kept by other Federal, state, or
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.
Complete lists of routine uses for this information are available in Systems of Records
Notice 60-0300 (Ticket-to-Work Program Manager (PM) Management Information
System). The Notice, additional information regarding this form, and information
regarding our systems and programs, are available on-line at www.ssa.gov or at your
local Social Security
Paperwork Reduction Act Statement - 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 XX 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 703-893-4020.
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.

Form SSA-1401 (05-2011)

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