Current SSA-1389

Form Approved
OMB No. 0960-0644

SOCIAL SECURITY ADMINISTRATION

EN Services Certification Statement
(For Use with Phase 1 Milestone 4 Request)
Ticket-Holder Name:

SSN:

Organization Name:

EIN #:

Date Individual Work Plan (IWP) Signed:

EN Supports/Services Agreed to in IWP

Date(s) Services Provided

1)

2)

3)

4)

5)

By signing below, the EN confirms that at least 50% of the agreed upon services have been provided to the beneficiary.
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.

EN Representative's Signature
Address:

Date
Telephone Number:

Optional:
In lieu of the above EN certification, the beneficiary may sign below;
I __________________________________ am satisfied with the employment services and supports provided by
_________________________________.

Beneficiary's Signature
Form SSA-1389 (xx-xxxx)

Date
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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 you from receiving 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. We estimate that it
5 minutes to read the instructions, gather the facts, and answer the questions. SEND
will take about XX
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-1389 (xx-xxxx)

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