Form SSA-1401 Employment Network Split Payment Request Form

Form Approved
OMB NO: 0960-0644

Social Security Administration

Employment Network Split Payment Request Form

Beneficiary SSN:

Employment Networks
Current EN:

Prior EN:

DUNS:

DUNS:

Ticket Assignment Date:

Ticket Assignment Date:

Contact Name:

Contact Name:

Phone:

Phone:

Prior EN:

Prior EN:

DUNS:

DUNS:

Ticket Assignment Date:

Ticket Assignment Date:

Contact Name:

Contact Name:

Phone:

Phone:

PROPOSED SPLIT PAYMENT

Please review the options below and indicate which split payment method would be most applicable to the
ENs requesting payment. [PLEASE NOTE: This applies for the duration of the
beneficiary’s ticket]

I WANT THE OPERATION SUPPORT MANAGER (OSM) TO MAKE
THE SPLIT PAYMENT DETERMINATION
Please check the box below to indicate that you would like
Operations Support Manager to determine the split payment percentages

I WANT THE OPERATIONS SUPPORT MANAGER TO USE
THE AGREED UPON SPLIT PAYENT ALLOCATION CHART BELOW

In the event there is two or more ENs involved in the split payment process for a beneficiary, the percentage
must be in denominations of 10 and the total for each payment request types should equal
to 100%. Remember the split will apply to all payment requests for the duration of the ticket.
Please refer to examples outlined below for assistance in filling out the chart.

Example #1 - Title II or Concurrent Beneficiary -- Two ENs involved
Payment
Types
Phase One
Milestones
Phase Two
Milestones
Outcome
Payments

Payment
Requests

Current En Name: Prior En#2 Name:
ABC, Inc
123 Company

P1M1-4

80%

20%

P2M1-11
O 1-36

90%
100%

10%
0%

Form SSA-1401 (02-2013)

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Prior EN#3
Name:

Prior EN#4
Name:

Form Approved
OMB NO: 0960-0644

Social Security Administration

Example #2 - Title16 Beneficiary - Three ENs involved
Payment
Requests

Payment
Types
Phase One
Milestones
Phase Two
Milestones
Outcome
Payments

Current En Name: Prior En#2 Name:
ABC, Inc
123 Company

Prior EN#3
Name:
XYZ, Inc

P1M1-4

30%

10%

60%

P2M1-18
O 1-10
O 11-60

40%
50%
70%

10%
0%
0%

50%
50%
30%

Prior EN#4
Name:

Split Payment Chart For Two Or More EN's
Following the examples above please fill out the chart below:
PAYMENT
TYPES

PAYMENT
REQUESTS

Current EN
Name:

Prior EN#1
Name:

Prior EN#2
Name:

Prior EN#3
Name:

Prior EN#4
Name:

Phase One
Milestones

Phase Two
Milestones

Outcome
Payments

We have discussed the services provided to the Ticket holder and agree to split the EN payments as requested above.

EN Signature:
EN Signature:
EN Signature:
EN Signature:

Date:
Date:
Date:
Date:

NOTE: Operations Support Manager will make the actual determination regarding the allocation of payments to EN’s
requesting payment for the same outcome, milestone, or reconciliation payment under its elected payment system.

Form SSA-1401 (02-2013)

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Collection and Use of Personal Information
Privacy Act Statement
See Revised Privacy Act and
PRA Statements 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 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 you from receiving 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 a 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 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.

Form SSA-1401 (02-2013)

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