SSA-1389 EN Certification of Services

Employment Network (EN) Certification
of Services (COS) Statement

EN Name:
DUNS Number:
Ticketholder Name:
Ticketholder SSN:
Ticketholder Telephone:
Ticketholder Email:
Ticketholder Address:

Ticket Assignment Date:
Ticket Unassignment Date (if applicable):

F-PMT-7014 NEW EN Certification of Services Statement V02

Individual Work Plan (IWP) Addendum: Statement of Services
Please list all services that your EN provided (include date) to the Ticketholder to date. These
services are those agreed upon in the IWP to help the Ticketholder reach and sustain his or her
long-term employment goals since both parties signed the IWP.

Social Security may verify the information above with the Ticketholder.
F-PMT-7014 NEW EN Certification of Services Statement V02

Did you attempt to contact the Ticketholder at least quarterly?
Yes
Dates of contact:
No

By signing below, the EN affirms having provided the services above to the Ticketholder.

EN Representative’s Name

EN Representative’s Signature

Date

F-PMT-7014 NEW EN Certification of Services Statement V02

Privacy Act Statement
Collection and Use of Personal Information
Section 1148 of the Social Security Act, as amended, allows us to collect this information. Furnishing us
this information is voluntary. However, failing to provide all or part of the information may prevent us
from assigning your ticket to your selected service provider.
We will use the information to monitor your progress in the Ticket to Work and Self Sufficiency
Program. We may also share your information for the following purposes, called routine uses:

•

Disclosure to contractors and other Federal agencies, as necessary, for the purpose of assisting
the Social Security Administration (SSA) in the efficient administration of its programs; and

•

Information may be disclosed to state or employment networks having an approved business
arrangement with SSA to perform vocational rehabilitation services for SSA disability
beneficiaries and recipients.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws.
For example, where authorized, we may use and disclose this information in computer matching
programs, in which our records are compared with other records to establish or verify a person’s
eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these
programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 600295, entitled Ticket-to-Work and Self-Sufficiency Program Payment Database, as published in the
Federal Register (FR) on April 4, 2001, at 66 FR 17985 and 60-0300, entitled Ticket-to-Work Program
Manager Management Information System, as published in the FR on June 15, 2001, at 66 FR 32656.
Additional information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.
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 10 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