Ticket Unassignment Form

Ticket Unassignment Form
Finding the right service provider is an important step on your journey toward financial
independence! If you have decided to end your relationship with your current provider, you
have the right to unassign your Ticket and take it to another provider.
If you have questions about your unassignment or about Ticket to Work, please call the Ticket
to Work Help Line at 866-968-7842 or 866-833-2967 (TTY) Monday through Friday, 8:00 a.m. to
8:00 p.m. ET.
To unassign your Ticket, please provide the following information:
Name:
Phone Number:
Social Security Number:
Employment Network (EN) Name:
Please identify the reason(s) you are unassigning your Ticket from this EN. Check all that apply.
Not satisfied with services
Cannot contact/ Non-responsive
Found another provider
No longer interested in participating in Ticket to Work
Health issues
Other
I,

request that my Ticket be unassigned from this EN.

Signature:
Mail this completed form to: Ticket Program Manager (TPM)
ATTN: Ticket Unassignment
P.O. Box 1433
Alexandria, VA 22313
Or fax it to 703-893-4020, ATTN: Ticket Unassignment

Date: