SSA-1396 Earnings Inquiry Request Form

DUNS Number: ____________

SOCIAL SECURITY ADMINISTRATION

Earnings Inquiry Request Form
INSTRUCTIONS: Submit this Earnings Inquiry Request (by email to SSAEarningsInquiry@MAXIMUS.com or fax to
703-893-4020) to request earnings information for Ticket-holders assigned to your organization prior to submitting
payment requests. Upon receiving this Earnings Inquiry Request (EIR), MAXIMUS will review quarterly wage earnings
records available to Social Security and respond in writing indicating whether the requested Ticket-holder has reported
earnings at or above three times Substantial Gainful Activity (SGA) for each calendar quarter available. Wage
earnings at this level in a quarter may mean that the beneficiary earned over SGA for each of the three months within
the quarter. This, in turn, may indicate that your EN is eligible for payment. Because there is some lag time between
the actual earnings period and the data appearance in Social Security administrative records, only calendar quarters
ending over five months ago will be available.
**Please Note the following points:
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Only written EIR requests will be accepted. Responses will not be given to verbal requests.
Because the quarterly wage records available to Social Security store earnings data for only the last 8
quarters, the oldest information available is 8 quarters plus 8 months back (for lag time), or just over 2 ½
years.
If this form is submitted via email, it must be sent by the named Signatory Authority, Primary Contact, or
Authorized Negotiator identified in your EN RFP/contract. If this form is faxed, it must be signed by the
same.
Earnings information is first available 8 months after the time period in which it was earned: 3 months for
the end of a quarter plus 5 months for the records to appear.
Earnings information is not available for time periods prior to the date of Ticket assignment.
This earnings information is intended to give you an indication of the beneficiary’s level of earnings to assist
you in deciding if you should request a payment. The information does not guarantee that you are
eligible for EN payment. Several other variables apply when granting EN payment. Even if the
beneficiary is reported with earnings over three times SGA for a quarter, the only way to determine if a
beneficiary has achieved payment outcomes is to submit a payment request to MAXIMUS.
Unfortunately, not all earnings information is available in Social Security administrative records. For
example, earnings may not be available for Ticket-holders who are self-employed or work for the Federal
government.

Complete the following portion of the form:
EN Name:
Your Name:

______________________

DUNS Number:

__________________________

_____________________

Signature:

___________________________

Request Date:

___________________________

(Must be an authorized representative)

Title:

______________________

Earnings Info Regarding Following Beneficiaries:
Social Security Number
(NO NAME)

Date of Ticket
Assignment

Social Security Number
(NO NAME)

Date of Ticket
Assignment

If you have any questions, please contact the MAXIMUS Ticket to Work office toll-free at 866-968-7842 (1-866-YourTicket).

F-PMT-7011 Earnings Inquiry Request Form V03