f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398

The Ticket to Work and Self-Sufficiency Program, 20 CFR 411

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0644 can be found here:

Documents and Forms

Document Name Document Type
DemoDeck.pptx Other-screens
SSA-1391 Employment Network Payment Request Form SSA 1391(revised).pdf Form and Instruction
SSA-1389 EN Services Certification Statement (For Use with Phase SSA 1389(revised).pdf Form and Instruction
SSA-1393 Employment Network Supplemental Earnings Statement SSA-1393 (revised).pdf Form and Instruction
SSA-1399 Auto Pay Request Form SSA 1399 (revised).pdf Form and Instruction
SSA-1396 Earnings Inquiry Request Form SSA-1396(current).pdf Form and Instruction
SSA-1398 Self-Employment Income (SEI) Form Beneficiary Quarterly SSA 1398(revised).pdf Form and Instruction
SSA 1389(current).pdf Current SSA-1389 IC Document
SSA 1391(current).pdf Current SSA-1391 IC Document
SSA-1393 (current).pdf Current SSA-1393 IC Document
SSA-1396(current).pdf Current SSA-1396 IC Document
SSA 1398(current).pdf Current SSA-1398 IC Document
SSA 1399 (current).pdf Current SSA-1399 IC Document

Information Collection (IC) Details

IC Title:	f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 411.575

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-screens			DemoDeck.pptx	Yes	Yes	Fillable Fileable
Form and Instruction	SSA-1399	Auto Pay Request Form	SSA 1399 (revised).pdf	Yes	No	Printable Only
Form and Instruction	SSA-1396	Earnings Inquiry Request Form	SSA-1396(current).pdf	Yes	No	Printable Only
Form and Instruction	SSA-1389	EN Services Certification Statement (For Use with Phase 1 Milestone 4 Request)	SSA 1389(revised).pdf	No		Paper Only
Form and Instruction	SSA-1398	Self-Employment Income (SEI) Form Beneficiary Quarterly Report Self-Employment	SSA 1398(revised).pdf	Yes	No	Printable Only
Form and Instruction	SSA-1391	Employment Network Payment Request Form	SSA 1391(revised).pdf	No		Paper Only
Form and Instruction	SSA-1393	Employment Network Supplemental Earnings Statement	SSA-1393 (revised).pdf	No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,805	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,805	2,805
Annual IC Time Burden (Hours)	1,870	1,870
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.