Current SSA-1401

Social Security Administration

Form Approved
OMB NO: 0960-0644
_______________________________________________________________________

Employment Network Split Payment Request Form
Beneficiary Name:

SSN:

Employment Networks
Current EN:
EIN:
Contact Name:
Phone:

Other EN:
EIN:
Contact Name:
Phone:

Other EN:
EIN:
Contact Name:
Phone:

Other EN:
EIN:
Contact Name:
Phone:

Proposed Payment Split
Please complete the appropriate box below to indicate the agreed upon payment split.

2 Way Split

Customized Split

Please circle the number above the combination
associated with the agreed upon percentage split.

Customized Split is only available for 3 or
more ENs.

Current
EN
Prior
EN

1

2

3

4

5

6

7

100

75

67

50

33

25

0

0

25

33

50

67

75

100

Employment Network

Payment
Percentage

1
2
3
4

We have discussed the services provided to the Ticket holder and agree to split the
EN payments as requested above.
EN Signature:
Date
EN Signature:
Date:
EN Signature:
Date:
EN Signature:
Date:
NOTE: Per 411.560 and 411.581 the Ticket Program Manager will make the actual determination
regarding the allocation of payments to EN’s requesting payment for the same outcome, milestone, or
reconciliation payment under its elected payment system.

_____________________________________________________________________________

Form SSA-1401 (xx-xxxx)

Page 1

Social Security Administration

Form Approved
OMB NO: 0960-0644
_______________________________________________________________________
Privacy Act Statement
Collection and Use of Personal Information
Public Law 106-170 and Section 1148 of the Social Security Act, as amended, authorize us to collect this
information. The information you provide will be used to document requirements towards achieving your
employment goal.
The information you furnish on this form is voluntary. However, failure to provide the requested
information could prevent you from pursuing your employment goal under the Ticket to Work program.
We rarely use the information you supply for any purpose other than for the Ticket to Work program.
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 the following:
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 Veterans’ Affairs);

3.

To State or Employment Networks having an approved business arrangement with Social
Security to perform vocational rehabilitation services for disability beneficiaries and
recipients; and,

4.

To facilitate 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
or administered benefit programs and for repayment of payments or delinquent debts under these programs.
Complete lists of routine uses for this information are available in Systems of Records Notice 60-0300
(Ticket-to-Work Program Manager (PM) Management Information System). The Notice, additional
information regarding this form, and information regarding our systems and programs, 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
20 minutes to read the
Budget control number. We estimate that it will take about XX
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 703683-3289. 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-1401 (xx-xxxx)

Page 2