Form SSA-1394 Employment Network Contract Change Form

Employment Network Blanket Purchase Agreement (BPA)
Change Form
Please Note: If this form is submitted via email it must be sent by the named Signatory
Authority or EN Other Contact identified in your EN BPA agreement with the Social Security
Administration. If this form is faxed, it must be signed by the same.
If you have any questions, please contact MAXIMUS Ticket to Work by email at
[email protected] or toll-free at 1-866-949-3687.
EN Name:
DUNS Number:
Your Name:
Title:
Signature:
Date of Request:

SECTION ONE
Changes to information in this section should be sent directly to [email protected] or faxed
to 410-597-0429 with a copy faxed to your Account Manager at 703-893-4020.
Directions: Please indicate the section(s) to which you wish to make changes by entering the
information in where indicated.
Update Mailing Address

Update Actual Address

Change Beneficiary Contact Information
Beneficiaries will be given this information in order to contact your EN.
Contact Name:
Phone:
Toll Free #:
Fax:
TTY:
Email:

Former contact no longer with the organization

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Change Signatory Authority Contact Information
Contact Name:
Phone:
Toll Free #:
Fax:
TTY:
Email:
Former contact no longer with the organization
Change Payment Contact Information
EN-designated contact to receive notices and statements and follow-up inquiries from the Social
Security Administration and the MAXIMUS EN Payment Department
Contact Name:
Phone:
Toll Free #:
Fax:
TTY:
Email:

SECTION TWO
Changes to information in this section should be sent directly to your Account Manager
Other EN Contact Information
EN designated contact OTHER than the Signatory Authority to receive/answer requests from
SSA concerning the EN BPA, and authorized to make changes to the BPA.
Contact Name:
Phone:
Toll Free #:
Fax:
TTY:
Email:

Former contact no longer with the organization

Change Payment Status Report Information
EN-designated contact to receive EN Payment Status Report from the MAXIMUS EN Payment
Department. This contact may be different than the EN Payment Information Contact.
Contact Name:
Phone:
Toll Free #:
Fax:
TTY:
Email:

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Add, Delete, or Change Doing Business As (DBA) Name
Add Name:
Change Name:
Delete Name:
Add, Delete, or Change Website Address
Add Address:
Change Address:
Delete Address:
Do you want a link to this website on the Employment Network Directory?

Yes

Add or Update Text Field
Display the following text below your EN name in the EN Directory (270 character maximum):

Change Type of Organization
Check all that apply.
Advocacy Group
Business/Employer
Community Based Organization
Education/Training
Faith-based Organization
Healthcare Provider
State/Local Government
Transportation/Transit
Add or Delete Preferred Impairment Groups Served
Add
Delete
Impairment Group:
Add
Delete
Impairment Group:
Add
Delete
Impairment Group:
Add
Delete
Impairment Group:
Add
Delete
Impairment Group:
Add or Delete Services Offered
Add
Delete
Service:
Add
Delete
Service:
Add
Delete
Service:
Add
Delete
Service:
Add
Delete
Service:

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No

Add or Delete Service Areas
National
Add
Multi-State
Add
Add
Add
Add
Add
Single State
Add

Serving all states and US Territories
Delete
List all states you wish to change
Delete
Delete
Delete
Delete
Delete

State:
State:
State:
State:
State:

List the state
Delete

State:

Add or Delete Counties Served
For each state you are serving select the county you wish to add or delete.
Add
Add
Add
Add
Add

Delete
Delete
Delete
Delete
Delete

State:
State:
State:
State:
State:

County:
County:
County:
County:
County:

Add or Delete Zip Codes Served
For each state you are serving select the zip code you wish to add or delete.
Add
Add
Add
Add
Add

Delete
Delete
Delete
Delete
Delete

State:
State:
State:
State:
State:

Zip Code:
Zip Code:
Zip Code:
Zip Code:
Zip Code:

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Add or Delete Service Locations
Add
Delete

Location
Address:

Preferred Impairment Groups Serviced at this Location:
Add
Add
Add
Add
Add
Add

Delete
Delete
Delete
Delete
Delete
Delete

Impairment Group:
Impairment Group:
Impairment Group:
Impairment Group:
Impairment Group:
Impairment Group:

Services Offered at this Location
Add
Add
Add
Add
Add
Add

Delete
Delete
Delete
Delete
Delete
Delete

Service:
Service:
Service:
Service:
Service:
Service:

Banking Information Notice
All banking information is changed directly on CCR.gov. There is no need to contact the Social
Security Administration or MAXIMUS. Please ensure that your Employment Network has an
active account on CCR.gov. To contact CCR.gov, please call 1-866-606-8220.

Novations
If you are changing your Employment Network Name, EIN or DUNS Number, you must contact
Erica Day directly at the Office of Acquisitions and Grants (OAG) at [email protected] or by
phone at 410-965-9512.

Suitability
When submitting contact change information suitability for new employees must also be
submitted to the address below. Please note the cover page MUST contain the following:
Contractor's Name, Contract Number, the Signatory Authority's Name, contact information, each
applicant's full name, Social Security number, date of birth and place of birth.
SSA
CPSPM Suitability Team
6401 Security Boulevard
Room 1260 Dunleavy Building
Baltimore, MD 21235
[email protected]

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