SSA-1389 EN Services Certification Statement (For Use with Phase

Form Approved
OMB No. 0960-0644

SOCIAL SECURITY ADMINISTRATION

EN Services Certification Statement
Employment Network Name:

DUNS Number:

Beneficiary Name:

Beneficiary Social Security Number:

Beneficiary Phone No:

Beneficiary Email:

Beneficiary Address:

When requesting any of the payments listed below, please fill-in Part 1 of this form concerning the provision of
previously agreed upon services and Part 2 to indicate the services you will provide in the future. Keep a copy
of this statement for your records.
Phase I, Milestone 4

Outcome 11

Phase 2, Milestone 11

Outcome 22

Part I: Statement of Services Provided
Please check the last plan of services submitted for the beneficiary, and insert the date
Individual Work Plan (IWP)
IWP Addendum: Statement of Future Services
Continuing Employment Support Agreed to in IWP or IWP Addendum (Include dates of service):

Initial Services Agreed to in IWP (Include dates of service):

By signing below, the EN confirms that at least 50% of the agreed upon services have been provided to the beneficiary.
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.

Beneficiary's Signature

Date

EN Representative's Signature

Date

Form SSA-1389 (02-2013)

Page 1

Form Approved
OMB No. 0960-0644

SOCIAL SECURITY ADMINISTRATION

Part 2: IWP Addendum - Statement of Future Services
Please list the future supports/services that you and the beneficiary agreed upon to help the beneficiary reach
and sustain his or her long-term goal. Quarterly contact is a required service. If there are no other agreed
upon services, please explain why.
Description of Supports/Services:

By signing below, the EN confirms that at least 50% of the agreed upon services have been provided to the beneficiary.
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.

Beneficiary's Signature

Date

EN Representative's Signature

Date

Form SSA-1389 (02-2013)

Page 1

Privacy Act Statement
Collection and Use of Personal Information
See Revised Privacy Act and
PRA Statement Attached.
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-1389 (02-2013)

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