SSA-1399 Auto Pay Request Form

Form Approved
OMB No. 0960-0644

SOCIAL SECURITY ADMINISTRATION

Universal Auto Pay (UAP) Request Form
Note: Certain requirements for eligibility apply. In order for your Employment Network (EN) to qualify
for Universal Auto Pay (UAP), you must meet the following criteria:
Ɣ
Ɣ

Have a current EN agreement with Social Security in good standing
Have at least five Tickets assigned

Ɣ

Have no overpayments or are able to pay back current overpayments

Please fill in the following in order to enroll in Unversal Auto Pay for ALL of your assigned
Ticket Holders.
EN Name:

DUNS Number:

Your Name:

Title:

By checking the box below, you are signing up to receive the following:
Ɣ
Ɣ

Quarterly Earnings alert for all your Ticket Holders to indicate who is working
above Trial Work Level (TWL)
Automated payments with the three month delay for Outcomes 1-12

Ɣ

Automated payments the following month for Outcomes 13 and beyond

Please place ALL of our assigned Ticket Holders on UAP.
By signing below, you as the EN agree to repay any payment(s) received or allow the amount to be deducted
from future payment(s) if it is determined at a later date that you were not entitled to the payment(s).

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.

Signature:

Date

Please fax this form to Operations Support Manager (OSM) at 703.893.4020.

Form SSA-1399 (02-2013)

Page 1

Privacy Act Statement
Collection and Use of Personal Information
See Revised Privacy Act and
PRA Statements Attached.
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 monitor the progress of a participant in the
Ticket to Work and Self Sufficiency Program. The information you furnish on this form is voluntary. However,
failure to provide all or part of the information requested on this form will prevent assignment of your Ticket to
Work to your selected provider of services.
We rarely use the information you supply for any purpose other than for monitoring the progress of a
participant in the Ticket to Work and Self Sufficiency 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:
(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; and

(4)

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 will
take about 3 minutes to read the instructions, gather the facts, and answer the questions. SEND THE
COMPLETED FORM TO: OPERATIONS SUPPORT MANAGER (OSM) TICKET TO WORK, PO BOX 1433,
ALEXANDRIA, VA 22313 OR FAX TO 703-893-4149. 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-1399 (02-2013)

Page 2

SSA will insert the following revised Privacy Act and PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information
Section 1148 of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from enrolling your Employment Network (EN) in Universal Auto
Pay (UAP).
We will use the information to enroll your EN in UAP. We may also share your information for
the following purposes, called routine uses:


Disclosure to contractors and other Federal agencies, as necessary, for the purpose of
assisting the Social Security Administration (SSA) in the efficient administration of its
programs; and



Information may be disclosed to state or employment networks having an approved
business arrangement with SSA to perform vocational rehabilitation services for SSA
disability beneficiaries and recipients.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0295, entitled Ticket-to-Work and Self-Sufficiency Program Payment Database, as
published in the Federal Register (FR) on April 4, 2001, at 66 FR 17985 and 60-0300, entitled
Ticket-to-Work Program Manager Management Information System, as published in the FR on
June 15, 2001, at 66 FR 32656. Additional information, and a full listing of all of our SORNs, is
available on our website at www.ssa.gov/privacy.

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 will take
about 10 minutes to read the instructions, gather the facts, and answer the questions.
SEND THE COMPLETED FORM TO: OPERATIONS SUPPORT MANAGER (OSM)
TICKET TO WORK, PO BOX 1433, ALEXANDRIA, VA 22313 OR FAX TO
703-893-4149. 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.