SSA-1391 Employment Network Payment Request Form

Form Approved
OMB No. 0960-0644

SOCIAL SECURITY ADMINISTRATION

Employment Network Payment Request Form
This form may be used 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 to SAM.GOV current?
Yes

No

(if No, please contact SAM @ 1-866-606-8220 before submitting this request)

Incorrect Or Outdated Information May Delay Or
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

Milestone-Outcome Payment Method

III. Phase 1 Milestone 1 Earnings Information
Select one option only if requesting a Phase I Milestone 1 payment.
The beneficiary acheived Trail Work Level (TWL) earnings during the calendar claim month.
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.

Form SSA-1391 (02-2013)

Page 1

Form Approved
OMB No. 0960-0644

SOCIAL SECURITY ADMINISTRATION

IV. Payment Request Details
Payment Request Type
A. Evidentiary Payment Request - (Complete Section IV)
B. Certification Payment Request - (Complete Sections V and VI)
Claim month(s) and year(s) for this payment request:
V. EN Services Details
Ɣ If requesting Phase 1 Milestone 1 , describe in detail the services provided since the ticket
assignment date.
Ɣ If requesting Phase 1 Milestone 2 or 3, describe in detail the services provided since the last
milestone payment month.
Milestone Payment

Date of Service

Description of Services

P1M-1
P1M-2
P1M-3
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
The Work Number

http://www.theworknumber.com/

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 the Operations Support
Manager (OSM)
Attached information containing data from the National Directory of New Hires (NDNH) or
Unemployment Compensation Insurance Record
Attached Self Employment Income (SEI) Form (if beneficiary is self-employed)

Form SSA-1391 (02-2013)

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Form Approved
OMB No. 0960-0644

SOCIAL SECURITY ADMINISTRATION

Recent Contact Details (complete only if you selected "recent contact with beneficiary):
Type of contact (phone call, email, etc):
Date of Contact:
Descriptions of information you learned from contact regarding level of earnings:

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.

VIII. Repayment Agreement (signature required):
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:

IX. Contact Information for the Employment Network Representative Submitting this Request
PRINT NAME:

PHONE NUMBER:

FAX:

EMAIL:

Form SSA-1391 (02-2013)

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Privacy Act Statement
Collection and Use of Personal Information
See Privacy Act
Statement

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 monitor the progress of a participant in the
Ticket to Work and Self Sufficiency Program. The information you furnish on this form is voluntary. However,
failure to provide all or part of the information requested on this form will prevent assignment of your Ticket to
Work to your selected provider of services.
We rarely use the information you supply for any purpose other than for monitoring the progress of a participant
in the Ticket to Work and Self Sufficiency 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:
(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; and

(4)

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 of Management and Budget control number. We estimate that it will
take about 3 minutes to read the instructions, gather the facts, and answer the questions. SEND THE
COMPLETED FORM TO: OPERATIONS SUPPORT MANAGER (OSM) TICKET TO WORK, Attn: Ticket
Assignment, PO BOX 1433, ALEXANDRIA, VA 22313 OR FAX TO 703-893-4149. 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-1391 (02-2013)

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SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:

Privacy Act Statement
Collection and Use of Personal Information
Section 1148 of the Social Security Act authorizes us to collect this information. We will use the
information to monitor the progress of a participant in the Ticket to Work and Self Sufficiency
Program.
Furnishing us this information is voluntary; however, failing to provide all or part of the
information may prevent payment to participant’s selected provider of services.
We rarely use the information you supply for any purpose other than what we state above,
however, we may use the information for the administration of our programs including sharing
information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census
and to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in
our Privacy Act System of Records Notice, 60-0295, entitled Ticket-to-Work and Self-Sufficiency
Program Payment Database, and 60-0300, entitled Ticket-to-Work Program Manager (PM)
Management Information System. Additional information about this and other system of
records notices and our programs are available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.
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
incorrect payments or delinquent debts under these programs.

SSA-1391