Form SSA-L1377 Timely Progress Requirements to Pass Each 12-month Timel

Social Security Administration
Request for Important Information

OMBNo. 0960-0644
Ticket to Work
P.O.Box 1433
Alexandria, VA 22313
March 21, 2012

Name
JYL
HUSKEY
IOWA
SERVICES
Name VOCATIONAL
of Employment REHABILITATION
Network
Address
510
E. 12TH STREET
City,MOINES,
State, ZipIA
Code
DES
50319
Re: Timely Progress Review - Request for Response
Our records show that the beneficiaries named on the attached Progress Review Form currently
have a ticket ”Assigned” or in ”In-use SVR” status with you. After every 12 months that the
beneficiary’s ticket is in one of these statuses, we ask about his or her progress toward a vocational
goal such as completing certain education or getting and keeping a job. We refer to this as a
”Timely Progress Review.” We are requesting your help in assessing whether these individuals are
making the expected progress because they did not respond to our request.
What You Should Do
Please complete the attached Progress Review Form and return it to us according to the instructions
on the form within 30 days of the date of this letter. We will notify you via a report concerning
whether these individuals met the Timely Progress Review requirements. The requirements for
each 12-month Timely Progress Review period are shown later in this letter.
Why Conduct Timely Progress Reviews
As long as the beneficiary is making the expected progress toward his or her vocational goal, Social
Security will not conduct a medical review to see if he or she is still disabled. We use the Timely
Progress Review to decide if a beneficiary is making enough progress with work and earnings,
education, or technical training to continue to be excused from a medical review.
The Timely Progress Review requirements enclosed with this letter show how much progress is
expected in each 12-month period. If a beneficiary is not making the expected progress, he or she
will no longer be excused from a medical review; however, the beneficiary may continue working
with your EN or State VR agency toward his or her vocational goals.

DUNS: 607308442

SSA-L1377

If You Have Questions
We are here to help you. If you have any questions regarding Timely Progress Reviews or the
Ticket to Work program, please call us at 1-866-968-7842 orTDD 1-866-833-2967. You may also fax
us at 703-893-4020 or write to us at the following address:
Ticket to Work
P.O. Box 1433
Alexandria, VA 22313
Sincerely,
Ticket to Work Program

DUNS: 607308442

SSA-L1377

Timely Progress Requirements to Pass
Each 12-month Timely Progress Review
1st 12Month
Review:

Complete 3 months of work at Trial Work Level amount (refer to Form for amount),
OR complete GED or high school diploma, OR complete 60% of a full-time course
load for an academic year in a college or technical, trade or vocational training
program, OR complete a combination of this work and education requirement.

2nd 12Month
Review:

Complete 6 months of work at Trial Work Level amounts (refer to Form for amount),
OR complete 75% of a full-time course load for an academic year in a college or
technical/trade/vocational training program, OR complete a combination of this
work and education requirement.

3rd 12Month
Review:

Complete 9 months of work at Substantial Gainful Activity amount (refer to Form
for amount), OR complete an additional full-time academic year of study, OR complete a 2-year or 4-year college program, OR complete a 2-year technical, trade or
vocational training program, OR complete a combination of this work and education requirement.

4th 12Month
Review:

Complete 9 months of work at SGA amount (refer to Form for amount), OR complete
an additional academic year of full-time study, OR complete a combination of this
work and education requirement

5th 12
Month
Review:

Complete 6 months of work at SGA amount (refer to Form for amount) with no SSDI
and/or SSI cash benefits in months worked,OR complete an additional academic
year of full-time study, OR complete a 4-year degree program.

6th 12
Month
Review:

Complete 6 months of work at SGA amount (refer to Form for amount) with no
SSDI and/ or SSI cash benefits in months worked, OR complete a 4-year degree
program.

7th 12
Month
Review:

Complete 6 months of work at SGA amount (refer to Form for amount) with no
SSDI and/or SSI cash benefits in months worked. *

* The guidelines for any subsequent 12-month Progress Review are the same as for the 7th 12-month
Progress Review

DUNS: 607308442

SSA-L1377

Ticket to Work Progress Review Form for DUNS: 607308442
03/21/2012
For each SSN shown in column one below, please look at the date of the individual’s progress
review period shown in column two. Then please fill out any other column(s) on that row that
applies to the individual. Only indicate work or educational credits you are aware the beneficiary
achieved during his or her progress review period. Write ”Yes” under the column that matches
the level of progress your client met during their 12-month progress review period, except certain
columns require that you insert the number of educational credits completed or the dollar amount
the beneficiary earned per month and the number of months worked. If there are no SSNs reported
for a specific 12-month Progress Review Period, skip the review period.
For example, always write ”yes” in column three when the individual has met the earnings
requirement. When an individual has fully met any single requirement for the period, you need
only indicate it in the appropriate box and the other boxes do not need to be completed. If the
beneficiary had a combination of earnings and education for the period, please fill in the last three
columns of the chart only to show the dollar amount earned per month and the number of months
worked during the 12-month period. In addition, write the number of credits completed in the
last column.
Leaving all columns blank for an SSN will indicate that you do not have information showing that
the individual met the Progress Review requirements.
Please sign, date, and return this form to Ticket to Work by fax at 703-893-4020 or by mail using
our address on the letter attached to this form. Please respond within 30 days of the date on this
form.
First 12-Month Progress Review

SSN
Progress
Review
Period

Earned
3 of 12
Months
>=$630*

High
School
Diploma
or GED

No. of
Credits
College

No. of
Credits
Vocational

********Combination********
Amount
No. of Credits
Earned
Months
Completed
per
worked
month

Second 12-Month Progress Review
********Combination********

DUNS: 607308442

SSA-L1377

SSN
Progress
Review
Period
479-72-3823

479-29-4966

482-68-7393

483-98-8505

478-02-5073

479-19-6591

482-96-5054

532-84-1692

Earned
6 of 12
Months
>=$630*

No. of
Credits
College

No. of Credits
Vocational

09/2010
thru
08/2011
09/2010
thru
08/2011
09/2010
thru
08/2011
09/2010
thru
08/2011
09/2010
thru
08/2011
09/2010
thru
08/2011
10/2010
thru
09/2011
12/2010
thru
11/2011

Amount
Earned
per
month

No. of
Months
worked

Credits
Completed

$

$

$

$

$

$

$

$

Third 12-Month Progress Review

SSN
Progress
Review
Period
480-92-9282

09/2010
thru
08/2011

DUNS: 607308442

Earned
9 of 12
Months
>=$882*

4-Year College
Additional
Year

Completed
2-Year College
or Vocational

********Combination********
Amount
No. of Credits
Earned
Months
Completed
per
worked
month
$

SSA-L1377

478-86-5149

483-90-5155

480-13-2223

497-92-9243

484-96-2828

505-23-1387

483-78-3572

319-74-3914

478-04-2665

539-68-9902

479-74-5882

10/2010
thru
09/2011
10/2010
thru
09/2011
10/2010
thru
09/2011
12/2010
thru
11/2011
12/2010
thru
11/2011
11/2010
thru
10/2011
11/2010
thru
10/2011
11/2010
thru
10/2011
11/2010
thru
10/2011
11/2010
thru
10/2011
11/2010
thru
10/2011

$

$

$

$

$

$

$

$

$

$

$

Fourth 12-Month Progress Review

SSN
Progress
Review
Period
DUNS: 607308442

Earned 9 of
12
Months
>=$882*

4-Year College
Additional
Year

********Combination********
Amount
No. of Credits
Earned
Months
Completed
per
worked
month
SSA-L1377

079-44-0149

482-08-2784

483-88-8994

478-08-6348

485-94-2678

478-17-7794

474-78-5393

480-06-1131

484-06-9756

482-04-6377

483-08-0542

483-80-1402

09/2010
thru
08/2011
09/2010
thru
08/2011
09/2010
thru
08/2011
09/2010
thru
08/2011
09/2010
thru
08/2011
09/2010
thru
08/2011
10/2010
thru
09/2011
10/2010
thru
09/2011
10/2010
thru
09/2011
10/2010
thru
09/2011
12/2010
thru
11/2011
11/2010
thru
10/2011

$

$

$

$

$

$

$

$

$

$

$

$

Fifth 12-Month Progress Review

DUNS: 607308442

SSA-L1377

SSN

006-70-2257

322-54-5051

600-60-9984

262-19-9998

485-92-0416

480-94-1104

480-13-6395

481-13-1751

Progress
Review
Period
09/2010
thru
08/2011
09/2010
thru
08/2011
09/2010
thru
08/2011
10/2010
thru
09/2011
10/2010
thru
09/2011
10/2010
thru
09/2011
11/2010
thru
10/2011
11/2010
thru
10/2011

Earned 6 of 12 Months
>=$882*
Months
No
SSI/SSDI

4-Year College
Additional
Year

4-Year College Completed

Sixth 12-Month Progress Review
SSN

393-78-2918

DUNS: 607308442

Progress
Review
Period
10/2010
thru
09/2011

Earned 6 of 12 >=$882*
Months No SSI/SSDI Cash
Payment

4-Year College Completed

SSA-L1377

Seventh and Subsequent 12-Month Progress Review
SSN

478-92-6025

481-80-2132

485-98-9173

499-86-5608

485-08-9918

Progress
Review
Period
09/2010
thru
08/2011
09/2010
thru
08/2011
09/2010
thru
08/2011
10/2010
thru
09/2011
10/2010
thru
09/2011

Earnings 6 of 12 >=$882* Months
No SSI/SSDI Cash Payment

*Amount represents 10% less than the Trial Work Level amount or the Substantial Gainful Activity
amount for the progress review period.
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 fine,
or imprisonment or both.
EN/SVRA Representative

DUNS: 607308442

Date

SSA-L1377

Collection and Use of Information from Your Progress Review Form
Privacy Act Statement
The Social Security Administration is authorized to collect the information on this form under
Public Law 106-170 and §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 review of your progress in the Ticket to Work Program. Although
responses to these questions are voluntary, you will not be able to pass the progress review and
remain excused from a medical review unless you answer the questions on this form.
Although the information you give us is almost never used for any other purpose than stated
above, 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 programs 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 the 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 us 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 Notice
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 15 minutes to read the instructions, gather the facts, and answer the questions. SEND THE
COMPLETED FORM TO TICKET TO WORK, PO BOX 1433, ALEXANDRIA, VA 22313, OR
FAX TO 703-893-4020. 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.
DUNS: 607308442

SSA-L1377