SSA-1393 Employment Network Supplemental Earnings Statement

Form Approved
OMB NO. 0960-0644

SOCIAL SECURITY ADMINISTRATION

Employment Network Supplemental Earnings Statement
If the primary evidence does not contain some required information, such as pay period end dates, please use
this table to provide any missing information.
EN Organization Name: _____________________________________________
EIN Number (Tax ID Number): _______________________________________
Beneficiary Name: __________________________________________________
Beneficiary Social Security Number: ___________________________________
Please complete the Earnings Evidence Table below, listing each pay period on each line separately. Feel free
to list multiple claim months for the same Ticket-holder on the same form.

Payment
Claimed
Month

Pay Period
Beginning

Pay
Period
Ending

Pay Date

Hours
Worked

Hourly
Rate

Total
Gross
Earnings

Year-to-date
Gross 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.

EN Representative Name:__________________________________________________
EN Representative Signature:_______________________________________________
Date: ____________________________________________________________________
Form SSA-1393 (xx-xxxx)

Page 1

Privacy Act Statement

See Revised 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 of Management and Budget control number.
5 minutes to read the instructions, gather the facts, and answer the
We estimate that it will take about XX
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-1393 (xx-xxxx)

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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 verify eligibility for payment.
Furnishing us this information is voluntary; however, failing to provide all or part of the information
could prevent receipt of payment.
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.

Form SSA-1393 (xx-xxxx)

Page 2