Current Version of the SSA-1365

Form Approved
OMB No. 0960-0641

STATE AGENCY TICKET ASSIGNMENT FORM
TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM
Instructions - This form must be completed to record that a beneficiary who is a ticket holder has decided to assign the ticket
to a State Vocational Rehabilitation (VR) Agency under an EN payment system. The form must be completed by both the
State VR agency representative and the ticket holder or, as appropriate, the ticket holder's representative. The State VR
agency will submit this form in lieu of submitting the Individualized Plan for Employment. If the ticket has never been assigned,
this form must be accompanied by the 18-month prior earnings look-back information. The ticket holder or his/her
representative, as appropriate must sign this form to confirm the decision to assign the ticket to the State VR agency. The
State VR agency will either send or fax the completed and signed form to:
Mail -

MAXIMUS Ticket to Work
ATTN: Ticket Assignment
P.O. Box 25105
Alexandria, VA 22313

Fax - 703-683-3289

A. To be Completed by State VR Agency (after verifying the beneficiary has a ticket which may be assigned to the
State VR agency)
1. Enter the State VR Agency's name

Enter the State VR Agency's Employer Identification Number (EIN)

2. Ticket Holder's Name (Last, First, Middle Initial)

3. Ticket Holder Number (This is the Social Security Number on the
ticket with the TW suffix.)
TW

4. (a) What vocational objective or employment outcome is outlined in the ticket holder's Individualized Plan for Employment?

(b) What is the expected type of job? (Check one EEOC classification below):
Executive/Managerial

Technical/Paraprofessional

Service Worker

Professional

Skilled Craft

Operative

Sales

Secretarial/Office/Clerical

Laborer

5. (a)
(a)Date
Datethe
theIndividualized
individualized Plan
Plan for
for Employment
Employment was
was signed
signed
bybyticket
ticketholder
hodlerororhis/her
his/herrepresentative
representative(month,
(month,day
dayyear)
year)

Other

5. (b) Date the Individualized Plan for Employment was signed
by the State VR agency counselor (month, day year)

6. In the Individualized Plan for Employment, date established for meeting the vocational objective chosen (month, year)
7. Please describe the services and supports to be provided to the beneficiary to accomplish the vocational goal in 4 above and help the
beneficiary's progress toward self-sufficiency:
a. Service during initial job acquisition and retention phase, i.e. services you plan to complete by the time the Phase 1, Milestone 4
payment is requested
(9 months of work attained)

b. Other services during ongoing support phases.

B. To be completed by the ticket holder or ticket holder's representative
Check the appropriate box and sign your name in the space provided below.
I am the ticket holder to whom the information on this form applies.
I am the representative of the ticket holder to whom the information on this form applies and am acting on his/her behalf.
I understand that once my ticket is assigned to the State VR agency, I have the right to retrieve my ticket for any reason. I
acknowledge that the information contained on this form relating to the ticket holder is correct, and that I do willingly agree to
assign my ticket to the State VR agency shown above.
I understand that if I make, or cause to be made, a representation which I know is false concerning the requirements of the Ticket
to Work and Self-Sufficiency program, I could be punished by a fine, or imprisonment, or both.
Ticket Holder or Representative Signature

State VR Agency Representative Signature

Date

Date

Form SSA-1365 (2-2009) Destroy Prior Editions

Collection and Use of Information from Your Ticket Assignment Form
Privacy Act Statement
The Social Security Administration is authorized to collect the information on this form
under Public Law 106-170 and section 1148 of the Social Security Act. While
furnishing the information on this form is voluntary, failure to provide all or part of the
information on this form to the Social Security Administration will prevent assignment
of your Ticket to Work to the provider of services chosen by you. The information
provided on this form will allow the Social Security Administration to monitor the
progress of a participant in the Ticket to Work and Self-Sufficiency Program.
Although the information you furnish on this form is almost never used for any other
purposes than stated in the foregoing, there is a possibility that for the administration
of the Social Security programs or for the administration of programs requiring
coordination with the Social Security Administration, information may be disclosed to
another person or to another government agency as follows: (1) to another Federal,
State, or local government agency for determining eligibility for a government benefit
or program; (2) to a Congressional office requesting information on behalf of the
program participant; (3) to a third party for the performance of research and statistical
activities; and (4) to the Department of Justice for use in representing the Federal
Government.
The information you provide may also be used without your consent in automated
matching programs. These matching program are computer comparisons of Social
Security Administration records with records kept by other Federal agencies or State
and local government agencies. Information from these matching programs can be
used to establish or verify a person's eligibility for federally funded or administered
benefit programs and for repayment of payments or delinquent debts under these
programs.
We may also use this information you give us when we match records by computer.
Matching programs compare our records with those of other Federal, State, or local
government agencies. Many agencies may use matching programs to find or prove
that a person qualifies for benefits paid by the Federal government. The law allows us
to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide may be used
or given out are available in Social Security offices. If you want to learn more about
this, contact any 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: 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.