SSA-1399 Auto Pay Request Form

Universal Auto Pay Request Form
Please fill in the following information in order to enroll in Universal Auto Pay for ALL of
your assigned Ticket-holders.
EN Name:
EIN:
DUNS Number:
Your Name:
Title:
By selecting the option below, you are signing up to receive the following:
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•
•

Quarterly Earnings alert for all your Ticket-holders to tell you who is
working above Trial Work Level (TWL)
Automated payments with the 3-month delay for Outcomes 1 – 12
Automated payments the following month for Outcomes 13 and beyond

Please place ALL of our assigned Ticket-holders on Universal Auto Pay.
Certain requirements for eligibility apply. In order for your EN to qualify for Universal
Auto Pay, you must meet all the following criteria:
•
•
•

Have a current EN agreement with SSA in good standing
Have at least five (5) Tickets assigned
Have no overpayments or be able to pay back current overpayments

In order to have your Ticket-holders placed on Auto Pay, you must also sign under the
following statement:
Note: 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

Date

Please fax this form to MAXIMUS at 703-893-4149. If you have any questions regarding
UAP or this form, call the Technical Assistance and Support Center (TASC).