Current SSA-1399

Form Approved
OMB No. 0960-0644

SOCIAL SECURITY ADMINISTRATION

Auto Pay Request Form
Please fill in the following information in order to request the “Auto Pay” option for one
or all of your assigned Ticket-holders.
EN Name: ______________________
EIN: ___________________________
Your Name:______________________
Title: ___________________________
Please select one of the following two options:
____ - Please place this Ticket-holder on Auto Pay, so that we may receive EN payment
without submitting payment requests.
Social Security Number: ________________________

____ - Please place ALL of our assigned Ticket-holders on Auto Pay.

In order to have a Ticket-holder placed on Auto Pay, you must also sign under the
following statement:
I declare under penalty of perjury that I have examined all the information on this
form, and on any accompanying statements or forms, and it is true and correct to
the best of my knowledge. I understand that anyone who knowingly gives a false or
misleading statement about a material fact in this information, or causes someone
else to do so, commits a crime and may be sent to prison, or may face other
penalties, or both.

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 703-683-0957 or call the Education and
Communications Department at 866-949-ENVR.

Form SSA-1399 (xx-xxxx)

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Privacy Act Statement
Collection and Use of Personal Information

Section 1148, of the Social Security Act, as amended, authorizes us to collect this
information. The information is needed to permit the Social Security Administration
(SSA) to verify eligibility for payment. The information you furnish on this form is
voluntary. However, failure to provide all or part of the information requested on this
form could prevent receipt of payment.
We rarely use the information you supply for any purpose other than verifying eligibility
for payment. 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:
(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 Veteran Affairs); (3) to make determinations
for eligibility in similar health and income maintenance programs at the Federal, State,
and local level; (4) to State agencies or Employment Networks having an approved
business arrangement with SSA to perform vocational rehabilitation services for
disability beneficiaries and recipients; and (5) to facilitate statistical research, 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 and administered benefit
programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Record
Notices 60-0295 and 60-0300. The notices, additional information regarding this form,
and information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at your local Social Security office.
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
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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 703-683-3289. 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-1399 (xx-xxxx)

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