SSA-1389 EN Services Certification Statement (For Use with Phase

EN SERVICES CERTIFICATION STATEMENT
Employment Network Name:
DUNS Number:
Beneficiary Name:
Beneficiary SSN:
Beneficiary Telephone:
Beneficiary Email:
Beneficiary Address:

When requesting any of the payments listed below, please fill-in Part 1 of this form concerning
the provision of previously agreed upon services and Part 2 to indicate the services you will
provide in the future. Keep a copy of this statement for your records.
Please select the EN Payment you are requesting:
Phase I, Milestone 4

Outcome 11

Phase II, Milestone 11

Outcome 22

F-PMT-7014 EN Services Certification Statement V06

Part 1: Statement of Services Provided
Please check the last plan of services submitted for the beneficiary, and insert the date.
Individual Work Plan (IWP)

Date:

IWP Addendum: Statement of Future Services

Date:

Initial Services Agreed to in IWP (Include dates of services):

Continuing Employment Support Agreed to in IWP or IWP Addendum
(Include dates of services):

By signing below, the EN confirms that at least 50% of the agreed upon services have been
provided. The beneficiary should sign below if he or she received the services shown above.
With the beneficiary’s permission, the EN may sign on the beneficiary’s behalf (i.e. John
Smith for Jane Doe).

Beneficiary’s Signature

Date

EN Representative’s Signature

Date

F-PMT-7014 EN Services Certification Statement V06

Part 2: IWP Addendum-Statement of Future Services
Please list the future supports/services that you and the beneficiary agreed upon to help the
beneficiary reach and sustain his or her long-term employment goal. Quarterly contact is a
required service. If there are no other agreed upon services, please explain why.
Description of Supports/Services:

By signing below, the EN and beneficiary confirm that they agreed to the future ongoing
employment supports listed above. With the beneficiary’s permission, the EN may sign on
the beneficiary’s behalf (i.e. John Smith for Jane Doe).

Beneficiary’s Signature

Date

EN Representative’s Signature

Date

F-PMT-7014 EN Services Certification Statement V06