Form SSA-1392 Employment Network Payment Status Report Request Form

Form Approved
OMB NO. 0960-0644

SOCIAL SECURITY ADMINISTRATION

Employment Network Payment Status Report Request Form
EN/State VR Agency Name:

EIN:

Employment Networks (ENs) have the option to receive a monthly status report of their EN Payment Requests submitted to
MAXIMUS. EN Payment Status Reports are available on the 15th day of each month and reflect activity for the previous
month, as well as year-to-date payment data. The report format includes the date each payment request was received by
MAXIMUS, beneficiary name, payment option, dollar amount paid, date paid, claim month(s), and the status of each
payment request submitted. The report is available in either printed or electronic format.
INSTRUCTIONS: If your organization would like to receive a monthly EN Payment Status Report, please indicate the
format in which you would like to receive this report and the mailing or email address to which you would like it sent.
Please sign, date, and return this form to MAXIMUS at the following address: MAXIMUS Ticket to Work, Attn: EN
Payments, P.O. Box 1433, Alexandria, VA 22313-5105, or fax it to MAXIMUS, Attn: EN Payments, (703) 683-1337.
[NOTE: Forms must be received by the end of the month in order for ENs to receive that month’s report on the 15th of the
following month.]

EN Payment Status Report
Please check the appropriate box to select either printed or electronic format (but not both).
Please forward the Employment Network Payment Status Report each month in the format indicated
below.



Printed

Organization Name: __________________________________________
Attn: (Name)________________________________________________
Street: _____________________________________________________
City/State/Zip: ______________________________________________



Electronic Email Address:______________________________________________
(Excel format)

I declare under penalty of perjury that I have examined all the information on this form, and on
any accompanying statements or forms, and it is true and correct to the best of my knowledge. I
understand that anyone who knowingly gives a false or misleading statement about a material
fact in this information, or causes someone else to do so, commits a crime and may be sent to
prison, or may face other penalties, or both.

Please sign and date below.
_____________________________________________
______________________
EN/State VR Agency Representative Signature
Date
____________________________________________________________________________
Form SSA-1392 (xx-xxxx)
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Privacy Act Statement
Collection and Use of Personal Information

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 receipt of 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 and/or 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.
5 minutes to read the instructions, gather the facts, and answer the
We estimate that it will take about XX
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-1392 (xx-xxxx)
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