Curren SSA-L1377

SOCIAL SECURITY ADMINISTRATION
Request for Important Information

Form Approved
OMB No. 0960-0644

MAXIMUS Ticket to Work
P.O. Box 1433
Alexandria, Virginia 22313
Date _____________
EN/SVRA POC: ________________________
Organization:
________________________
Address:
________________________
________________________
Re: 12-Month Progress Review – Request for Response
Our records indicate that the Ticket beneficiaries named on the attached Progress Review
Forms have been working with your organization. We have reviewed their Social Security
records but were unable to obtain evidence of earnings attained by these clients during
their applicable 12-month Progress Review period. Therefore, we are requesting your help
in assessing whether they are making the expected progress toward self-supporting
employment.
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. If we obtain your input
that your clients have met the requirements for this review period, they will pass their
current 12-month Progress Review and we will consider them to be making the expected
progress.
Why Progress Reviews are Important
As long as your clients are working with you and making the expected progress toward
their work-related goals, Social Security will not conduct a medical review to see if they
are still disabled under SSA rules. A Progress Review is the way Social Security decides if
your clients are making enough progress with work and education to continue to be
excused from a medical review.
The Timely Progress Review Guidelines enclosed with this letter show how much progress
your clients are expected to make in each 12-month period to continue to be excused from
a medical review. If they aren’t making the expected progress, your clients will not be
excused from a medical review. However, they may continue to work with your agency
toward their work goals.

_______________________________________________________________________________________
EIN:
Form SSA-L1377 (xx-xxxx)

If You Have Questions
As our valued partner in the Ticket to Work Program, we appreciate your interest and
commitment. We look forward to working with you to serve your needs. We invite you to
visit the www.yourtickettowork.com and www.socialsecurity.gov/work websites regularly
for program updates, general information, and training opportunities.
If you have any questions regarding the Ticket to Work Program, please fax us at 703-6830957 or contact us at 1-866-949-ENVR (1-866-949-3687) or TDD 1-866-833-2967. You
may also write to us at the following address:
MAXIMUS Ticket to Work
P. O. Box 1433
Alexandria, VA 22313
Sincerely,

MAXIMUS Ticket to Work Program

_______________________________________________________________________________________
EIN:
Form SSA-L1377 (xx-xxxx)

Timely Progress Review Requirements
During Each 12-month Review Period
1st-12 (after 12 months of ticket use) – complete 3 months of work at Trial Work Level
months (TWL), OR complete GED or high school diploma, OR complete 60% of a fulltime 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
2nd -12 (13-24 months of ticket use) – complete 6 months of work at Trial Work Level
months (TWL), 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-12 (25-36 months of ticket use) – complete 9 months of work at Substantial Gainful
months Activity (SGA) level, 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/vocational training program, OR complete a combination of this
work and education requirement
4th-12 (37-48 months of ticket use) – complete 9 months of work at Substantial Gainful
months Activity (SGA) level, OR complete an additional academic year of full-time
study, OR complete a combination of this work and education requirement
5th-12 (49-60 months of ticket use) – complete 6 months of work at Substantial Gainful
months Activity (SGA) level 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 (61-72 months of ticket use) – complete 6 months of work at Substantial Gainful
months Activity (SGA) level with no SSDI and/ or SSI cash benefits in months worked,
OR complete a 4-year degree program
7th-12 (73-84 months of ticket use) – complete 6 months of work at Substantial Gainful
months Activity (SGA) level 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.

_________________________________________________________________________
EIN:

Form SSA-L1377 (xx-xxxx)

Ticket to Work Progress Review Form for EIN:

For each SSN shown below, please write "Yes" under the column that matches the level of
progress your client met during their 12-month progress review period. The date of their
progress review period is also shown below.
If your client had a combination of earnings and education, please write the earnings
amount in the “amount earned” column, the number of “credits completed”, and the
number of credits required for a “full course load” academic year during the “dates of the
progress review period”.
Any SSN left blank will indicate that the client did not meet the Progress Review
requirements. Please sign, date, and return this form to MAXIMUS by fax at 703-6830957 or by mail using our address on the letter attached to this form.
Please respond within 30 days of the date on this form, no later than .
First 12-Month Progress Review
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|Earnings| High |
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|********Combination********|
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|Progress|3 of 12 |School |4-Year |2-Year or |Amount | Credits |Credits |
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|Review |Months |Diploma|College|Vocational|Earned |Completed|Full Load|
|SSN
|Period |>=$670 |or GED | 60% |
60%
|***************************|
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Second 12-Month Progress Review
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|Earnings|
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|********Combination********|
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|Progress|6 of 12 |4-Year |2-Year or | Amount| Credits |Credits |
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|Review |Months |College|Vocational| Earned|Completed|Full Load|
|SSN
|Period |>= $670 | 75% |
75%
|***************************|
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_______________________________________________________________________________________
EIN:
Form SSA-L1377 (xx-xxxx)

Third 12-Month Progress Review
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|Earnings| 4-Year
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|Progress|9 of 12 | College |Completed | Amount| Credits |Credits |
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|Review |Months |Additional|2-Year or | Earned|Completed|Full Load|
|SSN
|Period |>=$940 |Full Year |Vocational|***************************|
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Fourth 12-Month Progress Review
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|Earnings| 4-Year
|*********Combination*******|
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|Progress|9 of 12 | College | Amount| Credits | Credits |
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|Review |Months |Additional| Earned|Completed|Full Load|
|SSN
|Period |>=$940 |Full Year |***************************|
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Fifth 12-Month Progress Review
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| Earnings |
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| 6 of 12
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|Progress| >=$940
| College |
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|Review | Months
| Additional|
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|SSN
|Period |No SSI/SSDI| Full Year | 4-Year College Completed|
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_________________________________________________________________________________________________

EIN:

Form SSA-L1377 (xx-xxxx)

Sixth 12-Month Progress Review
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| Earnings |
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| 6 of 12
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|Progress| >=$940
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|Review | Months
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|SSN
|Period |No SSI/SSDI|4-Year College Completed|
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Seventh and Subsequent 12-Month Progress Review
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| Earnings |
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| 6 of 12
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|Progress| >=$940
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|Review | Months
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|SSN
|Period |No SSI/SSDI|
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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.

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

_________________________
Date

_________________________________________________________________________
EIN:

Form SSA-L1377 (xx-xxxx)

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 document requirements towards achieving employment goals. 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 beneficiaries from meeting employment
goals under the Ticket to Work program.
We rarely use the information you supply for any purpose other than documenting
requirements towards achieving employment goals. 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
Notice 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
15
of Management and Budget control number. We estimate that it will take about XX
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.
_______________________________________________________________________________________
EIN:
Form SSA-L1377 (xx-xxxx)