SSA-1396 Earnings Inquiry Request Form

Form Approved
OMB NO. 0960-0644

SOCIAL SECURITY ADMINISTRATION

EIN:

____________

Earnings Inquiry Request Form
INSTRUCTIONS: Submit this Earnings Inquiry Request (by email to [email protected] or fax to
703-683-3289) to request earnings information for Ticket-holders assigned to your organization prior to submitting
payment requests. Upon receiving this Earnings Inquiry Request (EIR), MAXIMUS will review quarterly wage earnings
records available to Social Security and respond in writing indicating whether the requested Ticket-holder has reported
earnings at or above three times Substantial Gainful Activity (SGA) for each calendar quarter available. Wage
earnings at this level in a quarter may mean that the beneficiary earned over SGA for each of the three months within
the quarter. This, in turn, may indicate that your EN is eligible for payment. Because there is some lag time between
the actual earnings period and the data appearance in Social Security administrative records, only calendar quarters
ending over five months ago will be available.
**Please Note the following points:
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Only written EIR requests will be accepted. Responses will not be given to verbal requests.
Because the quarterly wage records available to Social Security store earnings data for only the last 8
quarters, the oldest information available is 8 quarters plus 8 months back (for lag time), or just over 2 ½
years.
If this form is submitted via email, it must be sent by the named Signatory Authority, Primary Contact, or
Authorized Negotiator identified in your EN RFP/contract. If this form is faxed, it must be signed by the
same.
Earnings information is first available 8 months after the time period in which it was earned: 3 months for
the end of a quarter plus 5 months for the records to appear.
Earnings information is not available for time periods prior to the date of Ticket assignment.
This earnings information is intended to give you an indication of the beneficiary’s level of earnings to assist
you in deciding if you should request a payment. The information does not guarantee that you are
eligible for EN payment. Several other variables apply when granting EN payment. Even if the
beneficiary is reported with earnings over three times SGA for a quarter, the only way to determine if a
beneficiary has achieved payment outcomes is to submit a payment request to MAXIMUS.
Unfortunately, not all earnings information is available in Social Security administrative records. For
example, earnings may not be available for Ticket-holders who are self-employed or work for the Federal
government.

Form SSA-1396 (xx-xxxx)

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Complete the following portion of the form:

Earnings Info Regarding Following Beneficiaries:
Social Security Number
(NO NAME)

Date of Ticket
Assignment

Social Security Number
(NO NAME)

Date of Ticket
Assignment

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 Name:
Your Name:

___________________________
EIN:
___________________________
___________________________
(Must be an authorized representative)
Title:
___________________________
Signature:
___________________________
Date of Request:
___________________________

If you have any questions, please contact the MAXIMUS Ticket to Work office toll-free at 866-968-7842 (1-866-YourTicket).

Form SSA-1396 (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 of Management and Budget control number. We estimate that it
5 minutes to read the instructions, gather the facts, and answer the questions. SEND OR
will take about XX
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. 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-1396 (xx-xxxx)

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