Form SSA-1375 Ticket to Work Progress Review Form

Form Approved
SOCIAL SECURITY ADMINISTRATION

OMB No. 0960-0644

Progress Review Form
Beneficiary:
Provider:

SSN:

Date:

INSTRUCTIONS: Please inform us of your progress during the timeframe shown below by
completing one of the boxes in Sections A-E below. Check “Yes” or “No” and provide
information on progress with work and earnings, education, or technical training when
appropriate to indicate if you have met the first 12-Month Progress Review requirements.
Then sign, date, and return this form to MAXIMUS using the enclosed postage paid envelope
or by fax at 703-683-3289. It is important that you respond within 30 days of the date on this
form. You may retain a copy of this form for your records.

First 12-Month Progress Review Requirements
Between _______________________________ and ____________________________:

A. I worked 3 out of 12 months with earnings at or above $670 in each month (Trial
Work Level for 2008).
…Yes …No
If Yes, STOP here. Sign and date this form and mail or fax back to us.
OR
B. I obtained a GED or High School Diploma.

…Yes

…No

Name of Certifying Agency:_______________________________________________
Agency Address: ________________________________________________________
Date GED or Diploma Earned: _____________________________________________

If Yes, STOP here. Sign and date this form and mail or fax back to us.

EIN:
SSN:

_________________________________________________________________________
Form SSA-1375 (xx-xxxx)

Page 1

Progress Review Form (continued)
Beneficiary:
Provider:

SSN:

Date:

OR
C. I completed 60% of a full-time course load for a full academic year in a degree or
certification college program.
…Yes …No
School Name: __________________________________________________________
School Address: ________________________________________________________
# Credits Completed:______________ # Credits for full course load:______________
Date Completed:________________________________________________________
If Yes, STOP here. Sign and date this form and mail or fax back to us.
OR
D. I completed 60% of a full-time course load for an academic year in a Technical,
Trade, or Vocational program.
…Yes …No
School Name: __________________________________________________________
School Address: ________________________________________________________
# Credits Completed:______________ # Credits for full course load:______________
Date Completed:________________________________________________________
If Yes, STOP here. Sign and date this form and mail or fax back to us.
OR
E. I completed a combination of earnings PLUS some college degree or certification
credits or technical, trade, or vocational program credits that together equals or
exceeds 100%.
During this period I earned $__________.
AND
I completed _____ credits of a full-time course load in a degree or college
certification program or in a technical, trade, or vocational program.
School Name: __________________________________________________________
School Address: ________________________________________________________
# Credits for full course load:______________________________________________
Date Completed:________________________________________________________
Sign and date this form and mail or fax back to us.
EIN:
SSN:

_________________________________________________________________________
Form SSA-1375 (xx-xxxx)

Page 2

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.
I understand that if I make, or cause to be made, a representation which I know is
false concerning the requirements of the Ticket to Work and Self-Sufficiency
program, I could be punished by fine, or imprisonment or both.

_____________________________________
Beneficiary Signature

_________________________
Date

Return this form to MAXIMUS within 30 days using the enclosed postage-paid envelope
or by fax at 703-683-3289.

EIN:
SSN:

_________________________________________________________________________
Form SSA-1375 (xx-xxxx)

Page 3

See Revised
Privacy
Act
Privacy
Act Statement
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 document the requirements towards achieving your employment goal under the
Ticket to Work 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 you from pursuing your employment goal under the Ticket to Work program.
We rarely use the information you supply for any purpose other than documenting the
requirements towards achieving your employment goal under the Ticket to Work 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; (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
15
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.
EIN:
SSN:

________________________________________________________________________
Form SSA-1375 (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 document the requirements towards achieving your employment goal
under the Ticket to Work Program.
Furnishing us this information is voluntary; however, failing to provide all or part of the
information form will prevent you from pursuing your employment goal under the Ticket to
Work program.
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 SelfSufficiency 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-1375 (xx-xxxx)

Page 4