g) 20 CFR 411.325(f) - Periodic Outcomes Reporting

The Ticket to Work and Self-Sufficiency Program

TPR Selection Notices - Revised

g) 20 CFR 411.325(f) - Periodic Outcomes Reporting

OMB: 0960-0644

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0960-0644 can be found here:
2024-04-08 - No material or nonsubstantive change to a currently approved collection
2024-01-18 - No material or nonsubstantive change to a currently approved collection
Document [pdf]
Download: pdf | pdf
Social Security Administration
    Ticket to Work
    P.O. Box 1433
    Alexandria, VA 22313
    Date: July 28, 2015

DDFFAAFDFAFFDDFAADATAFFFDTFDADATFFFFDFAADAFDATTFDTFTAFTFATFFTDDAT

SAMPLE NOTICE
6401 SECURITY BLVD
BALTIMORE MD 21235-0001

Please complete the enclosed Progress Review Form SSA-1375 to tell us about
your progress from December 10, 2014 through December 31, 2014. Please see
the enclosed Timely Progress Review Chart for the requirements for the 1st
progress review. You must return the form within 30 days from the date of
this letter. Your reply is important. You may use the enclosed postage-paid
envelope or fax the form to 1-703-893-4020. Our return address is the first
address at the top of this notice.
We will review your answers to see if you have met the progress requirements
for the 1st progress review. We will not send you another letter if you have
made the required progress. We will send you another letter if we find that
you are not making timely progress. If you are not making the required
progress, we will no longer excuse you from scheduled medical reviews on your
disability case.
We encourage you to continue working with MARYLAND EMPLOYMENT
NETWORK toward your vocational goals.
If You Have Questions
We are here to help you. If you have any questions about your progress
review or the Ticket to Work program, call the Ticket Help Line, toll-free, at
1-866-968-7842 (TTY 1-866-833-2967). Or, you can visit our website,
http://www.socialsecurity.gov/work. You also may fax us at 703-893-4020, or
write to us at the address at the beginning of this notice.

See Next Page

0026010635600612017021235000101

What You Need To Do

000000000

We are writing to you because it is time for your 1st Timely Progress Review
under the Ticket to Work program. Our records show that you are receiving
employment support from MARYLAND EMPLOYMENT NETWORK. We must
decide if you are making the required progress toward your vocational goals.
To do this, we look at whether you are completing educational requirements,
and getting and keeping a job.

*0501Z08AB000028*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðõðñéðøÁÂððððòø\

Important Information

Page 2 of 9

For general questions about Social Security benefits, please visit Social
Security's website at http://www.socialsecurity.gov. You also may call Social
Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778), or you may write or
visit any Social Security office. They also can give you information about
other employment supports that help people with disabilities go to work. If
you visit a Social Security office, please take this letter with you.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the
Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

Enclosures:
Timely Progress Review Chart
Privacy Act and Paperwork Reduction Act
Progress Review Form SSA-1375
BRM Envelope ICN-588913

Page 3 of 9

Review Period: You must achieve at least one of the requirements listed
for your particular review period before we find that you have made
timely progress for that review period.    The review period is at least twelve
months long, and there is usually one review a year. In the list below, the
"Trial Work Level Amount" for 2015 is $780. The "Substantial Gainful Activity
Amount" for 2015 is $1,090. These amounts can increase slightly each year.
_________________________________________________________________

Third Review
 •     9 months of work at or above the substantial gainful activity amount;
  OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Complete a 2-year college program and earn a degree or certificate; OR
 •     Complete a technical, trade, or vocational training program.
_________________________________________________________________
Fourth Review
 •     9 months of work at or above the substantial gainful activity amount;
  OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education
  requirements.
_________________________________________________________________

0026010635600612017021235000101

Second Review
 •     6 months of work at or above the trial work level amount; OR
 •     Complete at least 75% of a full-time course load for an academic year
  in a 2-year or 4-year college or a technical, trade, or vocational training
  program; OR
 •     Complete a combination* of the above work and education
  requirements.
_________________________________________________________________

000000000

First Review
 •     3 months of work at or above the trial work level amount; OR
 •     Complete at least 60% of a full-time course load for an academic year
  in a 2-year or 4-year college or a technical, trade, or vocational training
  program; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Obtain a GED or high school diploma.
_________________________________________________________________

*0502Z08AB000028*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðõðòéðøÁÂððððòø\

Timely Progress Review Chart

Page 4 of 9

Fifth Review
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of Social Security Disability Insurance (SSDI) and
  Federal Supplemental Security Income (SSI) cash benefits; OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Complete a 4-year college program and earn a degree or certificate.
_________________________________________________________________
Sixth Review
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of SSDI and Federal SSI cash benefits; OR
 •     Complete a 4-year college program and earn a degree or certificate.
_________________________________________________________________
Seventh Review and Any Additional Reviews
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of SSDI and Federal SSI cash benefits.
* A "combination" means you can complete part of the work and part of the
education requirements. We will count the parts you complete as percentages.
Adding the two percentages together must equal 100% or more.

Page 5 of 9

CollectionŽandŽUseŽofŽPersonalŽInformation

See Revised Privacy Act
Statement Attached

Public Law 106-170 and Section 1148 of the Social Security Act, as amended,
authorize us to collect this information. We will use the information you
provide to determine if you have met the progress review requirements for the
Ticket to Work program.
Furnishing us this information is voluntary. However, failing to provide us
with all or part of the information may prevent review of your progress. In
order to be able to pass the progress review and remain excused from a medical
review, you should answer the questions on this form.

 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 our records (e.g., to the Government Accountability Office and
 Department of Veterans 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 and improvement of our programs
 (e.g., to the Bureau of the Census and to private entities under
 contract with us).

We may share the information you provide with other health agencies through
computer matching programs. Matching programs compare our records with
records kept by other Federal, State, or local government agencies. We use the
information from these programs to establish or verify a person's eligibility for
Federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
A complete list of when we may share your information with others, called
routine uses, is available in our Privacy Act Systems of Records Notices
entitled Electronic Disability (eDib) Claim File (60-0320); Ticket-to-Work and
Self-Sufficiency Program Payment Database (60-0295); and Ticket-to-Work
Program Manager (PM) Management Information System (60-0300). Additional
information about these and other systems of records notices and our programs
is available from our Internet website at www.socialsecurity.gov or at your
local Social Security office.

0026010635600612017021235000101

 1.

000000000

We rarely use the information you supply for any purpose other than your
progress review requirements under the Ticket to Work program. However, we
may use the information for the administration of our programs including
sharing information:

*0503Z08AB000028*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðõðóéðøÁÂððððòø\

   Privacy Act Statement

Page 6 of 9

  PaperworkŽReductionŽActŽNotice

This information collection meets the requirements of 44 U.S.C. section 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 15 minutes to
read the instructions, gather the facts, and answer the questions. 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.

Page 7 of 9

Form SSA-1375, OMB approved No. 0960-0644
_________________________________________________________________
Progress Review Form, 1st Review
RETURN THIS PAGE to Social Security, Ticket to Work
Beneficiary: JANE DOE
Social Security Number: 123-45-6789
 TW01
Provider: MARYLAND EMPLOYMENT NETWORK
Date: July 31, 2015
Your Review Period: From December 10, 2014 through December 10, 2014

2. I completed a two or four year college program during the review period
and earned a degree or certificate.
______ Yes
  ______ No
School Name: ____________________________________________________________
Month and Year of Completion: __________________________________________
_________________________________________________________________
3. I did not complete a two or four year college program, but I completed some
credits in a two or four year college program during the review period.
______ Yes
  ______ No
Number of credits completed ______
and number of credits needed to complete program ______
School Name: ____________________________________________________________
_________________________________________________________________

0026010635600612017021235000101

1. I worked at least three months of the review period with gross earnings at
or above $693.00 * in each of these months.
______ Yes
  ______ No
_________________________________________________________________

000000000

INSTRUCTIONS:    Please inform us of your progress for your review period
shown above by completing the items below on all remaining pages of this form
SSA-1375. Check "Yes" or "No" for each item and where you check "Yes"
provide any requested information on progress with work and earnings,
education, or technical training. Then sign, date, and return all pages of this
form SSA-1375 to Ticket to Work using the enclosed postage-paid envelope or
by fax at 1-703-893-4020.    It is important that you respond within 30 days of
the date on this form.   You may keep a copy of this form for your records.
_________________________________________________________________

*0504Z08AB000028*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðõðôéðøÁÂððððòø\

Social Security Administration

Page 8 of 9

4. I completed a technical, trade, or vocational program during the review
period.
______ Yes
  ______ No
School Name: ____________________________________________________________
Type of Program Completed: _____________________________________________
Month and Year of Completion: __________________________________________
_________________________________________________________________
5. I did not complete a technical, trade or vocational program, but I completed
some credits/ hours/ courses in a technical, trade, or vocational program during
the review period.
______ Yes
  ______ No
Number of credits/ hours/ courses completed ______
and number of credits/ hours/ courses needed to complete program ______
School Name: ____________________________________________________________
Type of Program: ________________________________________________________
_________________________________________________________________
6. I completed a combination of earnings PLUS two or four year college
credits or in a technical, trade or vocational program during the review
period.
______ Yes
  ______ No
I worked ______ months with gross earnings at or above $693.00 * in each of
these months.
I completed ______ credits/ hours/ courses in a two or four year college
program or in a technical, trade or vocational program and the number of
credits/ hours/ courses needed to complete program ______.
School Name: ____________________________________________________________
_________________________________________________________________
7. I obtained a GED or high school diploma during the review period.
______ Yes
  ______ No
Name of School or Agency Providing GED: _______________________________
Month and Year of Completion: __________________________________________
_________________________________________________________________

Page 9 of 9

 Sign and date this form and mail or fax back to us.

I understand that if I make, or cause to be made, a representation concerning
the requirements of the Ticket to Work and Self-Sufficiency Program which I
know is false, I could be punished by fine, or imprisonment, or both.
____________________________________
Signature

  ______________________________

Date

Form SSA-1375, Progress Review Form, 1st Review
Beneficiary: JANE DOE
Social Security Number: 123-45-6789
   TW01
RETURN THIS PAGE to Social Security, Ticket to Work

0026010635600612017021235000101

Ticket to Work
Social Security Administration
P.O. Box 1433
Alexandria, VA 22313

000000000

Return this form SSA-1375 to Ticket to Work within 30 days   using the
enclosed postage-paid envelope or by fax at 1-703-893-4020. Our return address
is:

*0505Z08AB000028*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðõðõéðøÁÂððððòø\

*Amount represents 90 percent of the Trial Work Level amount. This amount
can increase slightly each year.

Social Security Administration
    Ticket to Work
    P.O. Box 1433
    Alexandria, VA 22313
    Date: July 28, 2015

DAATTDDFAFTFTFAFFATADDTFTFFTAATAAADAFFDATDDFATFTTAATDTTAFTDDTAFDD

SAMPLE NOTICE
6401 SECURITY BLVD
BALTIMORE MD 21235-0001

Please complete the enclosed Progress Review Form SSA-1375 to tell us about
your progress from December 10, 2014 through December 31, 2014. Please see
the enclosed Timely Progress Review Chart for the requirements for the 2nd
progress review. You must return the form within 30 days from the date of
this letter. Your reply is important. You may use the enclosed postage-paid
envelope or fax the form to 1-703-893-4020. Our return address is the first
address at the top of this notice.
We will review your answers to see if you have met the progress requirements
for the 2nd progress review. We will not send you another letter if you have
made the required progress. We will send you another letter if we find that
you are not making timely progress. If you are not making the required
progress, we will no longer excuse you from scheduled medical reviews on your
disability case.
We encourage you to continue working with MARYLAND EMPLOYMENT
NETWORK toward your vocational goals.
If You Have Questions
We are here to help you. If you have any questions about your progress
review or the Ticket to Work program, call the Ticket Help Line, toll-free, at
1-866-968-7842 (TTY 1-866-833-2967). Or, you can visit our website,
http://www.socialsecurity.gov/work. You also may fax us at 703-893-4020, or
write to us at the address at the beginning of this notice.

See Next Page

0026010635600612016921235000101

What You Need To Do

000000000

We are writing to you because it is time for your 2nd Timely Progress Review
under the Ticket to Work program. Our records show that you are receiving
employment support from MARYLAND EMPLOYMENT NETWORK. We must
decide if you are making the required progress toward your vocational goals.
To do this, we look at whether you are completing educational requirements,
and getting and keeping a job.

*0501Z08AB000027*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðõðñéðøÁÂððððò÷\

Important Information

Page 2 of 9

For general questions about Social Security benefits, please visit Social
Security's website at http://www.socialsecurity.gov. You also may call Social
Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778), or you may write or
visit any Social Security office. They also can give you information about
other employment supports that help people with disabilities go to work. If
you visit a Social Security office, please take this letter with you.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the
Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

Enclosures:
Timely Progress Review Chart
Privacy Act and Paperwork Reduction Act
Progress Review Form SSA-1375
BRM Envelope ICN-588913

Page 3 of 9

Review Period: You must achieve at least one of the requirements listed
for your particular review period before we find that you have made
timely progress for that review period.    The review period is at least twelve
months long, and there is usually one review a year. In the list below, the
"Trial Work Level Amount" for 2015 is $780. The "Substantial Gainful Activity
Amount" for 2015 is $1,090. These amounts can increase slightly each year.
_________________________________________________________________

Third Review
 •     9 months of work at or above the substantial gainful activity amount;
  OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Complete a 2-year college program and earn a degree or certificate; OR
 •     Complete a technical, trade, or vocational training program.
_________________________________________________________________
Fourth Review
 •     9 months of work at or above the substantial gainful activity amount;
  OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education
  requirements.
_________________________________________________________________

0026010635600612016921235000101

Second Review
 •     6 months of work at or above the trial work level amount; OR
 •     Complete at least 75% of a full-time course load for an academic year
  in a 2-year or 4-year college or a technical, trade, or vocational training
  program; OR
 •     Complete a combination* of the above work and education
  requirements.
_________________________________________________________________

000000000

First Review
 •     3 months of work at or above the trial work level amount; OR
 •     Complete at least 60% of a full-time course load for an academic year
  in a 2-year or 4-year college or a technical, trade, or vocational training
  program; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Obtain a GED or high school diploma.
_________________________________________________________________

*0502Z08AB000027*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðõðòéðøÁÂððððò÷\

Timely Progress Review Chart

Page 4 of 9

Fifth Review
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of Social Security Disability Insurance (SSDI) and
  Federal Supplemental Security Income (SSI) cash benefits; OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Complete a 4-year college program and earn a degree or certificate.
_________________________________________________________________
Sixth Review
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of SSDI and Federal SSI cash benefits; OR
 •     Complete a 4-year college program and earn a degree or certificate.
_________________________________________________________________
Seventh Review and Any Additional Reviews
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of SSDI and Federal SSI cash benefits.
* A "combination" means you can complete part of the work and part of the
education requirements. We will count the parts you complete as percentages.
Adding the two percentages together must equal 100% or more.

Page 5 of 9

CollectionŽandŽUseŽofŽPersonalŽInformation

See Revised Privacy Act
Statement Attached

Public Law 106-170 and Section 1148 of the Social Security Act, as amended,
authorize us to collect this information. We will use the information you
provide to determine if you have met the progress review requirements for the
Ticket to Work program.
Furnishing us this information is voluntary. However, failing to provide us
with all or part of the information may prevent review of your progress. In
order to be able to pass the progress review and remain excused from a medical
review, you should answer the questions on this form.

 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 our records (e.g., to the Government Accountability Office and
 Department of Veterans 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 and improvement of our programs
 (e.g., to the Bureau of the Census and to private entities under
 contract with us).

We may share the information you provide with other health agencies through
computer matching programs. Matching programs compare our records with
records kept by other Federal, State, or local government agencies. We use the
information from these programs to establish or verify a person's eligibility for
Federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
A complete list of when we may share your information with others, called
routine uses, is available in our Privacy Act Systems of Records Notices
entitled Electronic Disability (eDib) Claim File (60-0320); Ticket-to-Work and
Self-Sufficiency Program Payment Database (60-0295); and Ticket-to-Work
Program Manager (PM) Management Information System (60-0300). Additional
information about these and other systems of records notices and our programs
is available from our Internet website at www.socialsecurity.gov or at your
local Social Security office.

0026010635600612016921235000101

 1.

000000000

We rarely use the information you supply for any purpose other than your
progress review requirements under the Ticket to Work program. However, we
may use the information for the administration of our programs including
sharing information:

*0503Z08AB000027*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðõðóéðøÁÂððððò÷\

   Privacy Act Statement

Page 6 of 9

  PaperworkŽReductionŽActŽNotice

This information collection meets the requirements of 44 U.S.C. section 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 15 minutes to
read the instructions, gather the facts, and answer the questions. 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.

Page 7 of 9

Form SSA-1375, OMB approved No. 0960-0644
_________________________________________________________________
Progress Review Form, 2nd Review
RETURN THIS PAGE to Social Security, Ticket to Work
Beneficiary: JANE DOE
Social Security Number: 123-45-6789
 TW01
Provider: MARYLAND EMPLOYMENT NETWORK
Date: July 31, 2015
Your Review Period: From December 10, 2014 through December 10, 2014

2. I completed a two or four year college program during the review period
and earned a degree or certificate.
______ Yes
  ______ No
School Name: ____________________________________________________________
Month and Year of Completion: __________________________________________
_________________________________________________________________
3. I did not complete a two or four year college program, but I completed some
credits in a two or four year college program during the review period.
______ Yes
  ______ No
Number of credits completed ______
and number of credits needed to complete program ______
School Name: ____________________________________________________________
_________________________________________________________________

0026010635600612016921235000101

1. I worked at least three months of the review period with gross earnings at
or above $693.00 * in each of these months.
______ Yes
  ______ No
_________________________________________________________________

000000000

INSTRUCTIONS:    Please inform us of your progress for your review period
shown above by completing the items below on all remaining pages of this form
SSA-1375. Check "Yes" or "No" for each item and where you check "Yes"
provide any requested information on progress with work and earnings,
education, or technical training. Then sign, date, and return all pages of this
form SSA-1375 to Ticket to Work using the enclosed postage-paid envelope or
by fax at 1-703-893-4020.    It is important that you respond within 30 days of
the date on this form.   You may keep a copy of this form for your records.
_________________________________________________________________

*0504Z08AB000027*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðõðôéðøÁÂððððò÷\

Social Security Administration

Page 8 of 9

4. I completed a technical, trade, or vocational program during the review
period.
______ Yes
  ______ No
School Name: ____________________________________________________________
Type of Program Completed: _____________________________________________
Month and Year of Completion: __________________________________________
_________________________________________________________________
5. I did not complete a technical, trade or vocational program, but I completed
some credits/ hours/ courses in a technical, trade, or vocational program during
the review period.
______ Yes
  ______ No
Number of credits/ hours/ courses completed ______
and number of credits/ hours/ courses needed to complete program ______
School Name: ____________________________________________________________
Type of Program: ________________________________________________________
_________________________________________________________________
6. I completed a combination of earnings PLUS two or four year college
credits or in a technical, trade or vocational program during the review
period.
______ Yes
  ______ No
I worked ______ months with gross earnings at or above $693.00 * in each of
these months.
I completed ______ credits/ hours/ courses in a two or four year college
program or in a technical, trade or vocational program and the number of
credits/ hours/ courses needed to complete program ______.
School Name: ____________________________________________________________
_________________________________________________________________
*Amount represents 90 percent of the Trial Work Level amount. This amount
can increase slightly each year.
 Sign and date this form and mail or fax back to us.

I understand that if I make, or cause to be made, a representation concerning
the requirements of the Ticket to Work and Self-Sufficiency Program which I
know is false, I could be punished by fine, or imprisonment, or both.
____________________________________
Signature

  ______________________________

Date

Page 9 of 9

Ticket to Work
Social Security Administration
P.O. Box 1433
Alexandria, VA 22313
Form SSA-1375, Progress Review Form, 2nd Review
Beneficiary: JANE DOE
Social Security Number: 123-45-6789
   TW01
RETURN THIS PAGE to Social Security, Ticket to Work

*0505Z08AB000027*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM
000000000
0026010635600612016921235000101

\ðõðõéðøÁÂððððò÷\

Return this form SSA-1375 to Ticket to Work within 30 days   using the
enclosed postage-paid envelope or by fax at 1-703-893-4020. Our return address
is:

Social Security Administration
    Ticket to Work
    P.O. Box 1433
    Alexandria, VA 22313
    Date: July 28, 2015

TTDTDTTDTDTTDAATDTDAFTDTTFTTTTDFTFTTFDDTTDAATAFFAFADFTFADDTTAFTDF

SAMPLE NOTICE
6401 SECURITY BLVD
BALTIMORE MD 21235-0001

Please complete the enclosed Progress Review Form SSA-1375 to tell us about
your progress from December 10, 2014 through December 31, 2014. Please see
the enclosed Timely Progress Review Chart for the requirements for the 3rd
progress review. You must return the form within 30 days from the date of
this letter. Your reply is important. You may use the enclosed postage-paid
envelope or fax the form to 1-703-893-4020. Our return address is the first
address at the top of this notice.
We will review your answers to see if you have met the progress requirements
for the 3rd progress review. We will not send you another letter if you have
made the required progress. We will send you another letter if we find that
you are not making timely progress. If you are not making the required
progress, we will no longer excuse you from scheduled medical reviews on your
disability case.
We encourage you to continue working with MARYLAND EMPLOYMENT
NETWORK toward your vocational goals.
If You Have Questions
We are here to help you. If you have any questions about your progress
review or the Ticket to Work program, call the Ticket Help Line, toll-free, at
1-866-968-7842 (TTY 1-866-833-2967). Or, you can visit our website,
http://www.socialsecurity.gov/work. You also may fax us at 703-893-4020, or
write to us at the address at the beginning of this notice.

See Next Page

0026010635600612017621235000101

What You Need To Do

000000000

We are writing to you because it is time for your 3rd Timely Progress Review
under the Ticket to Work program. Our records show that you are receiving
employment support from MARYLAND EMPLOYMENT NETWORK. We must
decide if you are making the required progress toward your vocational goals.
To do this, we look at whether you are completing educational requirements,
and getting and keeping a job.

*0501Z08AB000034*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðõðñéðøÁÂððððóô\

Important Information

Page 2 of 9

For general questions about Social Security benefits, please visit Social
Security's website at http://www.socialsecurity.gov. You also may call Social
Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778), or you may write or
visit any Social Security office. They also can give you information about
other employment supports that help people with disabilities go to work. If
you visit a Social Security office, please take this letter with you.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the
Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

Enclosures:
Timely Progress Review Chart
Privacy Act and Paperwork Reduction Act
Progress Review Form SSA-1375
BRM Envelope ICN-588913

Page 3 of 9

Review Period: You must achieve at least one of the requirements listed
for your particular review period before we find that you have made
timely progress for that review period.    The review period is at least twelve
months long, and there is usually one review a year. In the list below, the
"Trial Work Level Amount" for 2015 is $780. The "Substantial Gainful Activity
Amount" for 2015 is $1,090. These amounts can increase slightly each year.
_________________________________________________________________

Third Review
 •     9 months of work at or above the substantial gainful activity amount;
  OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Complete a 2-year college program and earn a degree or certificate; OR
 •     Complete a technical, trade, or vocational training program.
_________________________________________________________________
Fourth Review
 •     9 months of work at or above the substantial gainful activity amount;
  OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education
  requirements.
_________________________________________________________________

0026010635600612017621235000101

Second Review
 •     6 months of work at or above the trial work level amount; OR
 •     Complete at least 75% of a full-time course load for an academic year
  in a 2-year or 4-year college or a technical, trade, or vocational training
  program; OR
 •     Complete a combination* of the above work and education
  requirements.
_________________________________________________________________

000000000

First Review
 •     3 months of work at or above the trial work level amount; OR
 •     Complete at least 60% of a full-time course load for an academic year
  in a 2-year or 4-year college or a technical, trade, or vocational training
  program; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Obtain a GED or high school diploma.
_________________________________________________________________

*0502Z08AB000034*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðõðòéðøÁÂððððóô\

Timely Progress Review Chart

Page 4 of 9

Fifth Review
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of Social Security Disability Insurance (SSDI) and
  Federal Supplemental Security Income (SSI) cash benefits; OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Complete a 4-year college program and earn a degree or certificate.
_________________________________________________________________
Sixth Review
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of SSDI and Federal SSI cash benefits; OR
 •     Complete a 4-year college program and earn a degree or certificate.
_________________________________________________________________
Seventh Review and Any Additional Reviews
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of SSDI and Federal SSI cash benefits.
* A "combination" means you can complete part of the work and part of the
education requirements. We will count the parts you complete as percentages.
Adding the two percentages together must equal 100% or more.

Page 5 of 9

See Revised Privacy Act
Statement Attached

CollectionŽandŽUseŽofŽPersonalŽInformation

Public Law 106-170 and Section 1148 of the Social Security Act, as amended,
authorize us to collect this information. We will use the information you
provide to determine if you have met the progress review requirements for the
Ticket to Work program.
Furnishing us this information is voluntary. However, failing to provide us
with all or part of the information may prevent review of your progress. In
order to be able to pass the progress review and remain excused from a medical
review, you should answer the questions on this form.

 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 our records (e.g., to the Government Accountability Office and
 Department of Veterans 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 and improvement of our programs
 (e.g., to the Bureau of the Census and to private entities under
 contract with us).

We may share the information you provide with other health agencies through
computer matching programs. Matching programs compare our records with
records kept by other Federal, State, or local government agencies. We use the
information from these programs to establish or verify a person's eligibility for
Federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
A complete list of when we may share your information with others, called
routine uses, is available in our Privacy Act Systems of Records Notices
entitled Electronic Disability (eDib) Claim File (60-0320); Ticket-to-Work and
Self-Sufficiency Program Payment Database (60-0295); and Ticket-to-Work
Program Manager (PM) Management Information System (60-0300). Additional
information about these and other systems of records notices and our programs
is available from our Internet website at www.socialsecurity.gov or at your
local Social Security office.

0026010635600612017621235000101

 1.

000000000

We rarely use the information you supply for any purpose other than your
progress review requirements under the Ticket to Work program. However, we
may use the information for the administration of our programs including
sharing information:

*0503Z08AB000034*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðõðóéðøÁÂððððóô\

   Privacy Act Statement

Page 6 of 9

  PaperworkŽReductionŽActŽNotice

This information collection meets the requirements of 44 U.S.C. section 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 15 minutes to
read the instructions, gather the facts, and answer the questions. 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.

Page 7 of 9

Form SSA-1375, OMB approved No. 0960-0644
_________________________________________________________________
Progress Review Form, 3rd Review
RETURN THIS PAGE to Social Security, Ticket to Work
Beneficiary: JANE DOE
Social Security Number: 123-45-6789
 TW01
Provider: MARYLAND EMPLOYMENT NETWORK
Date: July 31, 2015
Your Review Period: From December 10, 2014 through December 10, 2014

2. I completed a two or four year college program during the review period
and earned a degree or certificate.
______ Yes
  ______ No
School Name: ____________________________________________________________
Month and Year of Completion: __________________________________________
_________________________________________________________________
3. I did not complete a two or four year college program, but I completed some
credits in a two or four year college program during the review period.
______ Yes
  ______ No
Number of credits completed ______
and number of credits needed to complete program ______
School Name: ____________________________________________________________
_________________________________________________________________

0026010635600612017621235000101

1. I worked at least three months of the review period with gross earnings at
or above $693.00 * in each of these months.
______ Yes
  ______ No
_________________________________________________________________

000000000

INSTRUCTIONS:    Please inform us of your progress for your review period
shown above by completing the items below on all remaining pages of this form
SSA-1375. Check "Yes" or "No" for each item and where you check "Yes"
provide any requested information on progress with work and earnings,
education, or technical training. Then sign, date, and return all pages of this
form SSA-1375 to Ticket to Work using the enclosed postage-paid envelope or
by fax at 1-703-893-4020.    It is important that you respond within 30 days of
the date on this form.   You may keep a copy of this form for your records.
_________________________________________________________________

*0504Z08AB000034*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðõðôéðøÁÂððððóô\

Social Security Administration

Page 8 of 9

3. I completed a combination of earnings PLUS two or four year college
credits or in a technical, trade or vocational program during the review
period.
______ Yes
  ______ No
I worked ______ months with gross earnings at or above $693.00 * in each of
these months.
I completed ______ credits/ hours/ courses in a two or four year college
program or in a technical, trade or vocational program and the number of
credits/ hours/ courses needed to complete program ______.
School Name: ____________________________________________________________
_________________________________________________________________
4. I completed a technical, trade, or vocational program during the review
period.
______ Yes
  ______ No
School Name: ____________________________________________________________
Type of Program Completed: _____________________________________________
Month and Year of Completion: __________________________________________
_________________________________________________________________
*Amount represents 90 percent of the Substantial Gainful Activity amount.
This amount can increase slightly each year.
 Sign and date this form and mail or fax back to us.

I understand that if I make, or cause to be made, a representation concerning
the requirements of the Ticket to Work and Self-Sufficiency Program which I
know is false, I could be punished by fine, or imprisonment, or both.
____________________________________
Signature

  ______________________________

Date

Return this form SSA-1375 to Ticket to Work within 30 days   using the
enclosed postage-paid envelope or by fax at 1-703-893-4020. Our return address
is:
Ticket to Work
Social Security Administration
P.O. Box 1433
Alexandria, VA 22313
Form SSA-1375, Progress Review Form, 3rd Review
Beneficiary: JANE DOE
Social Security Number: 123-45-6789
   TW01

Page 9 of 9

*0505Z08AB000034*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

000000000

0026010635600612017621235000101

\ðõðõéðøÁÂððððóô\

RETURN THIS PAGE to Social Security, Ticket to Work

Social Security Administration
    Ticket to Work
    P.O. Box 1433
    Alexandria, VA 22313
    Date: July 28, 2015

DATFTFTFFFDDADAFTAAATDDADDFDTAAADATFDFDDTTDTFTATFAFFTTTDDTFDTAAAD

SAMPLE NOTICE
6401 SECURITY BLVD
BALTIMORE MD 21235-0001

Please complete the enclosed Progress Review Form SSA-1375 to tell us about
your progress from December 10, 2014 through December 31, 2014. Please see
the enclosed Timely Progress Review Chart for the requirements for the 4th
progress review. You must return the form within 30 days from the date of
this letter. Your reply is important. You may use the enclosed postage-paid
envelope or fax the form to 1-703-893-4020. Our return address is the first
address at the top of this notice.
We will review your answers to see if you have met the progress requirements
for the 4th progress review. We will not send you another letter if you have
made the required progress. We will send you another letter if we find that
you are not making timely progress. If you are not making the required
progress, we will no longer excuse you from scheduled medical reviews on your
disability case.
We encourage you to continue working with MARYLAND EMPLOYMENT
NETWORK toward your vocational goals.
If You Have Questions
We are here to help you. If you have any questions about your progress
review or the Ticket to Work program, call the Ticket Help Line, toll-free, at
1-866-968-7842 (TTY 1-866-833-2967). Or, you can visit our website,
http://www.socialsecurity.gov/work. You also may fax us at 703-893-4020, or
write to us at the address at the beginning of this notice.

See Next Page

0026010635600612018221235000101

What You Need To Do

000000000

We are writing to you because it is time for your 4th Timely Progress Review
under the Ticket to Work program. Our records show that you are receiving
employment support from MARYLAND EMPLOYMENT NETWORK. We must
decide if you are making the required progress toward your vocational goals.
To do this, we look at whether you are completing educational requirements,
and getting and keeping a job.

*0401Z08AB000040*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðôðñéðøÁÂððððôð\

Important Information

Page 2 of 8

For general questions about Social Security benefits, please visit Social
Security's website at http://www.socialsecurity.gov. You also may call Social
Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778), or you may write or
visit any Social Security office. They also can give you information about
other employment supports that help people with disabilities go to work. If
you visit a Social Security office, please take this letter with you.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the
Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

Enclosures:
Timely Progress Review Chart
Privacy Act and Paperwork Reduction Act
Progress Review Form SSA-1375
BRM Envelope ICN-588913

Page 3 of 8

Review Period: You must achieve at least one of the requirements listed
for your particular review period before we find that you have made
timely progress for that review period.    The review period is at least twelve
months long, and there is usually one review a year. In the list below, the
"Trial Work Level Amount" for 2015 is $780. The "Substantial Gainful Activity
Amount" for 2015 is $1,090. These amounts can increase slightly each year.
_________________________________________________________________

Third Review
 •     9 months of work at or above the substantial gainful activity amount;
  OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Complete a 2-year college program and earn a degree or certificate; OR
 •     Complete a technical, trade, or vocational training program.
_________________________________________________________________
Fourth Review
 •     9 months of work at or above the substantial gainful activity amount;
  OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education
  requirements.
_________________________________________________________________

0026010635600612018221235000101

Second Review
 •     6 months of work at or above the trial work level amount; OR
 •     Complete at least 75% of a full-time course load for an academic year
  in a 2-year or 4-year college or a technical, trade, or vocational training
  program; OR
 •     Complete a combination* of the above work and education
  requirements.
_________________________________________________________________

000000000

First Review
 •     3 months of work at or above the trial work level amount; OR
 •     Complete at least 60% of a full-time course load for an academic year
  in a 2-year or 4-year college or a technical, trade, or vocational training
  program; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Obtain a GED or high school diploma.
_________________________________________________________________

*0402Z08AB000040*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðôðòéðøÁÂððððôð\

Timely Progress Review Chart

Page 4 of 8

Fifth Review
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of Social Security Disability Insurance (SSDI) and
  Federal Supplemental Security Income (SSI) cash benefits; OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Complete a 4-year college program and earn a degree or certificate.
_________________________________________________________________
Sixth Review
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of SSDI and Federal SSI cash benefits; OR
 •     Complete a 4-year college program and earn a degree or certificate.
_________________________________________________________________
Seventh Review and Any Additional Reviews
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of SSDI and Federal SSI cash benefits.
* A "combination" means you can complete part of the work and part of the
education requirements. We will count the parts you complete as percentages.
Adding the two percentages together must equal 100% or more.

Page 5 of 8

See Revised Privacy Act
Statement Attached

CollectionŽandŽUseŽofŽPersonalŽInformation

Public Law 106-170 and Section 1148 of the Social Security Act, as amended,
authorize us to collect this information. We will use the information you
provide to determine if you have met the progress review requirements for the
Ticket to Work program.
Furnishing us this information is voluntary. However, failing to provide us
with all or part of the information may prevent review of your progress. In
order to be able to pass the progress review and remain excused from a medical
review, you should answer the questions on this form.

 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 our records (e.g., to the Government Accountability Office and
 Department of Veterans 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 and improvement of our programs
 (e.g., to the Bureau of the Census and to private entities under
 contract with us).

We may share the information you provide with other health agencies through
computer matching programs. Matching programs compare our records with
records kept by other Federal, State, or local government agencies. We use the
information from these programs to establish or verify a person's eligibility for
Federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
A complete list of when we may share your information with others, called
routine uses, is available in our Privacy Act Systems of Records Notices
entitled Electronic Disability (eDib) Claim File (60-0320); Ticket-to-Work and
Self-Sufficiency Program Payment Database (60-0295); and Ticket-to-Work
Program Manager (PM) Management Information System (60-0300). Additional
information about these and other systems of records notices and our programs
is available from our Internet website at www.socialsecurity.gov or at your
local Social Security office.

0026010635600612018221235000101

 1.

000000000

We rarely use the information you supply for any purpose other than your
progress review requirements under the Ticket to Work program. However, we
may use the information for the administration of our programs including
sharing information:

*0403Z08AB000040*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðôðóéðøÁÂððððôð\

   Privacy Act Statement

Page 6 of 8

  PaperworkŽReductionŽActŽNotice

This information collection meets the requirements of 44 U.S.C. section 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 15 minutes to
read the instructions, gather the facts, and answer the questions. 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.

Page 7 of 8

Form SSA-1375, OMB approved No. 0960-0644
_________________________________________________________________
Progress Review Form, 4th Review
RETURN THIS PAGE to Social Security, Ticket to Work
Beneficiary: JANE DOE
Social Security Number: 123-45-6789
 TW01
Provider: MARYLAND EMPLOYMENT NETWORK
Date: July 31, 2015
Your Review Period: From December 10, 2014 through December 10, 2014

2. I completed a four year college program during the review period and
earned a degree or certificate.
______ Yes
  ______ No
School Name: ____________________________________________________________
Month and Year of Completion: __________________________________________
_________________________________________________________________
3. I did not complete a four year college program, but I completed some credits
in a four year college program during the review period.
______ Yes
  ______ No
Number of credits completed ______
and number of credits needed to complete program ______
School Name: ____________________________________________________________
_________________________________________________________________

0026010635600612018221235000101

1. I worked at least nine months of the review period with gross earnings at
or above $963.00 * in each of these months.
______ Yes
  ______ No
_________________________________________________________________

000000000

INSTRUCTIONS:    Please inform us of your progress for your review period
shown above by completing the items below on all remaining pages of this form
SSA-1375. Check "Yes" or "No" for each item and where you check "Yes"
provide any requested information on progress with work and earnings,
education, or technical training. Then sign, date, and return all pages of this
form SSA-1375 to Ticket to Work using the enclosed postage-paid envelope or
by fax at 1-703-893-4020.    It is important that you respond within 30 days of
the date on this form.   You may keep a copy of this form for your records.
_________________________________________________________________

*0404Z08AB000040*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðôðôéðøÁÂððððôð\

Social Security Administration

Page 8 of 8

4. I completed a combination of earnings PLUS four year college credits
during the review period.
______ Yes
  ______ No
I worked ______ months with gross earnings at or above $963.00 * in each of
these months.
I completed ______ credits/ hours/ courses in a four year college program and
the number of credits/ hours/ courses needed to complete program ______.
School Name: ____________________________________________________________
_________________________________________________________________
*Amount represents 90 percent of the Substantial Gainful Activity amount.
This amount can increase slightly each year.
 Sign and date this form and mail or fax back to us.

I understand that if I make, or cause to be made, a representation concerning
the requirements of the Ticket to Work and Self-Sufficiency Program which I
know is false, I could be punished by fine, or imprisonment, or both.
____________________________________
Signature

  ______________________________

Date

Return this form SSA-1375 to Ticket to Work within 30 days   using the
enclosed postage-paid envelope or by fax at 1-703-893-4020. Our return address
is:
Ticket to Work
Social Security Administration
P.O. Box 1433
Alexandria, VA 22313
Form SSA-1375, Progress Review Form, 4th Review
Beneficiary: JANE DOE
Social Security Number: 123-45-6789
   TW01
RETURN THIS PAGE to Social Security, Ticket to Work

Social Security Administration
    Ticket to Work
    P.O. Box 1433
    Alexandria, VA 22313
    Date: July 28, 2015

DDDTATADAAADFFFADDTTFFAATAFATDTTAFAAFFADDFDAFTDFATAFFFTTTDDFTDTDT

SAMPLE NOTICE
6401 SECURITY BLVD
BALTIMORE MD 21235-0001

Please complete the enclosed Progress Review Form SSA-1375 to tell us about
your progress from December 10, 2014 through December 31, 2014. Please see
the enclosed Timely Progress Review Chart for the requirements for the 5th
progress review. You must return the form within 30 days from the date of
this letter. Your reply is important. You may use the enclosed postage-paid
envelope or fax the form to 1-703-893-4020. Our return address is the first
address at the top of this notice.
We will review your answers to see if you have met the progress requirements
for the 5th progress review. We will not send you another letter if you have
made the required progress. We will send you another letter if we find that
you are not making timely progress. If you are not making the required
progress, we will no longer excuse you from scheduled medical reviews on your
disability case.
We encourage you to continue working with MARYLAND EMPLOYMENT
NETWORK toward your vocational goals.
If You Have Questions
We are here to help you. If you have any questions about your progress
review or the Ticket to Work program, call the Ticket Help Line, toll-free, at
1-866-968-7842 (TTY 1-866-833-2967). Or, you can visit our website,
http://www.socialsecurity.gov/work. You also may fax us at 703-893-4020, or
write to us at the address at the beginning of this notice.

See Next Page

0026010635600612018121235000101

What You Need To Do

000000000

We are writing to you because it is time for your 5th Timely Progress Review
under the Ticket to Work program. Our records show that you are receiving
employment support from MARYLAND EMPLOYMENT NETWORK. We must
decide if you are making the required progress toward your vocational goals.
To do this, we look at whether you are completing educational requirements,
and getting and keeping a job.

*0401Z08AB000039*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðôðñéðøÁÂððððóù\

Important Information

Page 2 of 8

For general questions about Social Security benefits, please visit Social
Security's website at http://www.socialsecurity.gov. You also may call Social
Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778), or you may write or
visit any Social Security office. They also can give you information about
other employment supports that help people with disabilities go to work. If
you visit a Social Security office, please take this letter with you.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the
Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

Enclosures:
Timely Progress Review Chart
Privacy Act and Paperwork Reduction Act
Progress Review Form SSA-1375
BRM Envelope ICN-588913

Page 3 of 8

Review Period: You must achieve at least one of the requirements listed
for your particular review period before we find that you have made
timely progress for that review period.    The review period is at least twelve
months long, and there is usually one review a year. In the list below, the
"Trial Work Level Amount" for 2015 is $780. The "Substantial Gainful Activity
Amount" for 2015 is $1,090. These amounts can increase slightly each year.
_________________________________________________________________

Third Review
 •     9 months of work at or above the substantial gainful activity amount;
  OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Complete a 2-year college program and earn a degree or certificate; OR
 •     Complete a technical, trade, or vocational training program.
_________________________________________________________________
Fourth Review
 •     9 months of work at or above the substantial gainful activity amount;
  OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education
  requirements.
_________________________________________________________________

0026010635600612018121235000101

Second Review
 •     6 months of work at or above the trial work level amount; OR
 •     Complete at least 75% of a full-time course load for an academic year
  in a 2-year or 4-year college or a technical, trade, or vocational training
  program; OR
 •     Complete a combination* of the above work and education
  requirements.
_________________________________________________________________

000000000

First Review
 •     3 months of work at or above the trial work level amount; OR
 •     Complete at least 60% of a full-time course load for an academic year
  in a 2-year or 4-year college or a technical, trade, or vocational training
  program; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Obtain a GED or high school diploma.
_________________________________________________________________

*0402Z08AB000039*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðôðòéðøÁÂððððóù\

Timely Progress Review Chart

Page 4 of 8

Fifth Review
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of Social Security Disability Insurance (SSDI) and
  Federal Supplemental Security Income (SSI) cash benefits; OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Complete a 4-year college program and earn a degree or certificate.
_________________________________________________________________
Sixth Review
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of SSDI and Federal SSI cash benefits; OR
 •     Complete a 4-year college program and earn a degree or certificate.
_________________________________________________________________
Seventh Review and Any Additional Reviews
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of SSDI and Federal SSI cash benefits.
* A "combination" means you can complete part of the work and part of the
education requirements. We will count the parts you complete as percentages.
Adding the two percentages together must equal 100% or more.

Page 5 of 8

CollectionŽandŽUseŽofŽPersonalŽInformation

See Revised Privacy Act
Statement Attached

Public Law 106-170 and Section 1148 of the Social Security Act, as amended,
authorize us to collect this information. We will use the information you
provide to determine if you have met the progress review requirements for the
Ticket to Work program.
Furnishing us this information is voluntary. However, failing to provide us
with all or part of the information may prevent review of your progress. In
order to be able to pass the progress review and remain excused from a medical
review, you should answer the questions on this form.

 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 our records (e.g., to the Government Accountability Office and
 Department of Veterans 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 and improvement of our programs
 (e.g., to the Bureau of the Census and to private entities under
 contract with us).

We may share the information you provide with other health agencies through
computer matching programs. Matching programs compare our records with
records kept by other Federal, State, or local government agencies. We use the
information from these programs to establish or verify a person's eligibility for
Federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
A complete list of when we may share your information with others, called
routine uses, is available in our Privacy Act Systems of Records Notices
entitled Electronic Disability (eDib) Claim File (60-0320); Ticket-to-Work and
Self-Sufficiency Program Payment Database (60-0295); and Ticket-to-Work
Program Manager (PM) Management Information System (60-0300). Additional
information about these and other systems of records notices and our programs
is available from our Internet website at www.socialsecurity.gov or at your
local Social Security office.

0026010635600612018121235000101

 1.

000000000

We rarely use the information you supply for any purpose other than your
progress review requirements under the Ticket to Work program. However, we
may use the information for the administration of our programs including
sharing information:

*0403Z08AB000039*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðôðóéðøÁÂððððóù\

   Privacy Act Statement

Page 6 of 8

  PaperworkŽReductionŽActŽNotice

This information collection meets the requirements of 44 U.S.C. section 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 15 minutes to
read the instructions, gather the facts, and answer the questions. 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.

Page 7 of 8

Form SSA-1375, OMB approved No. 0960-0644
_________________________________________________________________
Progress Review Form, 5th Review
RETURN THIS PAGE to Social Security, Ticket to Work
Beneficiary: JANE DOE
Social Security Number: 123-45-6789
 TW01
Provider: MARYLAND EMPLOYMENT NETWORK
Date: July 31, 2015
Your Review Period: From December 10, 2014 through December 10, 2014

2. I completed a four year college program during the review period and
earned a degree or certificate.
______ Yes
  ______ No
School Name: ____________________________________________________________
Month and Year of Completion: __________________________________________
_________________________________________________________________
3. I did not complete a four year college program, but I completed some credits
in a four year college program during the review period.
______ Yes
  ______ No
Number of credits completed ______
and number of credits needed to complete program ______
School Name: ____________________________________________________________
_________________________________________________________________

0026010635600612018121235000101

1. I worked at least six months of the review period with gross earnings at or
above $1070.00 * in each of these months, and for these same months did not
receive payment of cash benefits from Social Security Disability Insurance
(SSDI) and Federal Supplemental Security Income (SSI).
______ Yes
  ______ No
_________________________________________________________________

000000000

INSTRUCTIONS:    Please inform us of your progress for your review period
shown above by completing the items below on all remaining pages of this form
SSA-1375. Check "Yes" or "No" for each item and where you check "Yes"
provide any requested information on progress with work and earnings,
education, or technical training. Then sign, date, and return all pages of this
form SSA-1375 to Ticket to Work using the enclosed postage-paid envelope or
by fax at 1-703-893-4020.    It is important that you respond within 30 days of
the date on this form.   You may keep a copy of this form for your records.
_________________________________________________________________

*0404Z08AB000039*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðôðôéðøÁÂððððóù\

Social Security Administration

Page 8 of 8

4. I completed a combination of earnings PLUS four year college credits
during the review period.
______ Yes
  ______ No
I worked ______ months with gross earnings at or above $1070.00 * in each of
these months.
I completed ______ credits/ hours/ courses in a four year college program and
the number of credits/ hours/ courses needed to complete program ______.
School Name: ____________________________________________________________
_________________________________________________________________
*Amount represents the full Substantial Gainful Activity amount. This amount
can increase slightly each year.
 Sign and date this form and mail or fax back to us.

I understand that if I make, or cause to be made, a representation concerning
the requirements of the Ticket to Work and Self-Sufficiency Program which I
know is false, I could be punished by fine, or imprisonment, or both.
____________________________________
Signature

  ______________________________

Date

Return this form SSA-1375 to Ticket to Work within 30 days   using the
enclosed postage-paid envelope or by fax at 1-703-893-4020. Our return address
is:
Ticket to Work
Social Security Administration
P.O. Box 1433
Alexandria, VA 22313
Form SSA-1375, Progress Review Form, 5th Review
Beneficiary: JANE DOE
Social Security Number: 123-45-6789
   TW01
RETURN THIS PAGE to Social Security, Ticket to Work

Social Security Administration
    Ticket to Work
    P.O. Box 1433
    Alexandria, VA 22313
    Date: July 28, 2015

TFTFFFAFDTFTTTFDTFFTTAFTDTTDTFFDDAADDTATDATTTATTFDFDAFFFTDAAATTAA

SAMPLE NOTICE
6401 SECURITY BLVD
BALTIMORE MD 21235-0001

Please complete the enclosed Progress Review Form SSA-1375 to tell us about
your progress from December 10, 2014 through December 31, 2014. Please see
the enclosed Timely Progress Review Chart for the requirements for the 6th
progress review. You must return the form within 30 days from the date of
this letter. Your reply is important. You may use the enclosed postage-paid
envelope or fax the form to 1-703-893-4020. Our return address is the first
address at the top of this notice.
We will review your answers to see if you have met the progress requirements
for the 6th progress review. We will not send you another letter if you have
made the required progress. We will send you another letter if we find that
you are not making timely progress. If you are not making the required
progress, we will no longer excuse you from scheduled medical reviews on your
disability case.
We encourage you to continue working with MARYLAND EMPLOYMENT
NETWORK toward your vocational goals.
If You Have Questions
We are here to help you. If you have any questions about your progress
review or the Ticket to Work program, call the Ticket Help Line, toll-free, at
1-866-968-7842 (TTY 1-866-833-2967). Or, you can visit our website,
http://www.socialsecurity.gov/work. You also may fax us at 703-893-4020, or
write to us at the address at the beginning of this notice.

See Next Page

0026010635600612017921235000101

What You Need To Do

000000000

We are writing to you because it is time for your 6th Timely Progress Review
under the Ticket to Work program. Our records show that you are receiving
employment support from MARYLAND EMPLOYMENT NETWORK. We must
decide if you are making the required progress toward your vocational goals.
To do this, we look at whether you are completing educational requirements,
and getting and keeping a job.

*0401Z08AB000037*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðôðñéðøÁÂððððó÷\

Important Information

Page 2 of 8

For general questions about Social Security benefits, please visit Social
Security's website at http://www.socialsecurity.gov. You also may call Social
Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778), or you may write or
visit any Social Security office. They also can give you information about
other employment supports that help people with disabilities go to work. If
you visit a Social Security office, please take this letter with you.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the
Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

Enclosures:
Timely Progress Review Chart
Privacy Act and Paperwork Reduction Act
Progress Review Form SSA-1375
BRM Envelope ICN-588913

Page 3 of 8

Review Period: You must achieve at least one of the requirements listed
for your particular review period before we find that you have made
timely progress for that review period.    The review period is at least twelve
months long, and there is usually one review a year. In the list below, the
"Trial Work Level Amount" for 2015 is $780. The "Substantial Gainful Activity
Amount" for 2015 is $1,090. These amounts can increase slightly each year.
_________________________________________________________________

Third Review
 •     9 months of work at or above the substantial gainful activity amount;
  OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Complete a 2-year college program and earn a degree or certificate; OR
 •     Complete a technical, trade, or vocational training program.
_________________________________________________________________
Fourth Review
 •     9 months of work at or above the substantial gainful activity amount;
  OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education
  requirements.
_________________________________________________________________

0026010635600612017921235000101

Second Review
 •     6 months of work at or above the trial work level amount; OR
 •     Complete at least 75% of a full-time course load for an academic year
  in a 2-year or 4-year college or a technical, trade, or vocational training
  program; OR
 •     Complete a combination* of the above work and education
  requirements.
_________________________________________________________________

000000000

First Review
 •     3 months of work at or above the trial work level amount; OR
 •     Complete at least 60% of a full-time course load for an academic year
  in a 2-year or 4-year college or a technical, trade, or vocational training
  program; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Obtain a GED or high school diploma.
_________________________________________________________________

*0402Z08AB000037*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðôðòéðøÁÂððððó÷\

Timely Progress Review Chart

Page 4 of 8

Fifth Review
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of Social Security Disability Insurance (SSDI) and
  Federal Supplemental Security Income (SSI) cash benefits; OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Complete a 4-year college program and earn a degree or certificate.
_________________________________________________________________
Sixth Review
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of SSDI and Federal SSI cash benefits; OR
 •     Complete a 4-year college program and earn a degree or certificate.
_________________________________________________________________
Seventh Review and Any Additional Reviews
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of SSDI and Federal SSI cash benefits.
* A "combination" means you can complete part of the work and part of the
education requirements. We will count the parts you complete as percentages.
Adding the two percentages together must equal 100% or more.

Page 5 of 8

CollectionŽandŽUseŽofŽPersonalŽInformation

See Revised Privacy Act
Statement Attached

Public Law 106-170 and Section 1148 of the Social Security Act, as amended,
authorize us to collect this information. We will use the information you
provide to determine if you have met the progress review requirements for the
Ticket to Work program.
Furnishing us this information is voluntary. However, failing to provide us
with all or part of the information may prevent review of your progress. In
order to be able to pass the progress review and remain excused from a medical
review, you should answer the questions on this form.

 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 our records (e.g., to the Government Accountability Office and
 Department of Veterans 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 and improvement of our programs
 (e.g., to the Bureau of the Census and to private entities under
 contract with us).

We may share the information you provide with other health agencies through
computer matching programs. Matching programs compare our records with
records kept by other Federal, State, or local government agencies. We use the
information from these programs to establish or verify a person's eligibility for
Federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
A complete list of when we may share your information with others, called
routine uses, is available in our Privacy Act Systems of Records Notices
entitled Electronic Disability (eDib) Claim File (60-0320); Ticket-to-Work and
Self-Sufficiency Program Payment Database (60-0295); and Ticket-to-Work
Program Manager (PM) Management Information System (60-0300). Additional
information about these and other systems of records notices and our programs
is available from our Internet website at www.socialsecurity.gov or at your
local Social Security office.

0026010635600612017921235000101

 1.

000000000

We rarely use the information you supply for any purpose other than your
progress review requirements under the Ticket to Work program. However, we
may use the information for the administration of our programs including
sharing information:

*0403Z08AB000037*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðôðóéðøÁÂððððó÷\

   Privacy Act Statement

Page 6 of 8

  PaperworkŽReductionŽActŽNotice

This information collection meets the requirements of 44 U.S.C. section 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 15 minutes to
read the instructions, gather the facts, and answer the questions. 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.

Page 7 of 8

Form SSA-1375, OMB approved No. 0960-0644
_________________________________________________________________
Progress Review Form, 6th Review
RETURN THIS PAGE to Social Security, Ticket to Work
Beneficiary: JANE DOE
Social Security Number: 123-45-6789
 TW01
Provider: MARYLAND EMPLOYMENT NETWORK
Date: July 31, 2015
Your Review Period: From December 10, 2014 through December 10, 2014

2. I completed a four year college program during the review period and
earned a degree or certificate.
______ Yes
  ______ No
School Name: ____________________________________________________________
Month and Year of Completion: __________________________________________
_________________________________________________________________

0026010635600612017921235000101

1. I worked at least six months of the review period with gross earnings at or
above $1070.00 * in each of these months, and for these same months did not
receive payment of cash benefits from Social Security Disability Insurance
(SSDI) and Federal Supplemental Security Income (SSI).
______ Yes
  ______ No
_________________________________________________________________

000000000

INSTRUCTIONS:    Please inform us of your progress for your review period
shown above by completing the items below on all remaining pages of this form
SSA-1375. Check "Yes" or "No" for each item and where you check "Yes"
provide any requested information on progress with work and earnings,
education, or technical training. Then sign, date, and return all pages of this
form SSA-1375 to Ticket to Work using the enclosed postage-paid envelope or
by fax at 1-703-893-4020.    It is important that you respond within 30 days of
the date on this form.   You may keep a copy of this form for your records.
_________________________________________________________________

*0404Z08AB000037*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðôðôéðøÁÂððððó÷\

Social Security Administration

Page 8 of 8

*Amount represents the full Substantial Gainful Activity amount. This amount
can increase slightly each year.
 Sign and date this form and mail or fax back to us.

I understand that if I make, or cause to be made, a representation concerning
the requirements of the Ticket to Work and Self-Sufficiency Program which I
know is false, I could be punished by fine, or imprisonment, or both.
____________________________________
Signature

  ______________________________

Date

Return this form SSA-1375 to Ticket to Work within 30 days   using the
enclosed postage-paid envelope or by fax at 1-703-893-4020. Our return address
is:
Ticket to Work
Social Security Administration
P.O. Box 1433
Alexandria, VA 22313
Form SSA-1375, Progress Review Form, 6th Review
Beneficiary: JANE DOE
Social Security Number: 123-45-6789
   TW01
RETURN THIS PAGE to Social Security, Ticket to Work

Social Security Administration
    Ticket to Work
    P.O. Box 1433
    Alexandria, VA 22313
    Date: July 28, 2015

FDADFAFATAFATFDTFFADFAFFFADDFDFTTDFDAAAAFFTDAFTFTTDTDFDFAATFDDFFA

SAMPLE NOTICE
6401 SECURITY BLVD
BALTIMORE MD 21235-0001

Please complete the enclosed Progress Review Form SSA-1375 to tell us about
your progress from December 10, 2014 through December 31, 2014. Please see
the enclosed Timely Progress Review Chart for the requirements for the 7th
progress review. You must return the form within 30 days from the date of
this letter. Your reply is important. You may use the enclosed postage-paid
envelope or fax the form to 1-703-893-4020. Our return address is the first
address at the top of this notice.
We will review your answers to see if you have met the progress requirements
for the 7th progress review. We will not send you another letter if you have
made the required progress. We will send you another letter if we find that
you are not making timely progress. If you are not making the required
progress, we will no longer excuse you from scheduled medical reviews on your
disability case.
We encourage you to continue working with MARYLAND EMPLOYMENT
NETWORK toward your vocational goals.
If You Have Questions
We are here to help you. If you have any questions about your progress
review or the Ticket to Work program, call the Ticket Help Line, toll-free, at
1-866-968-7842 (TTY 1-866-833-2967). Or, you can visit our website,
http://www.socialsecurity.gov/work. You also may fax us at 703-893-4020, or
write to us at the address at the beginning of this notice.

See Next Page

0026010635600612018021235000101

What You Need To Do

000000000

We are writing to you because it is time for your 7th Timely Progress Review
under the Ticket to Work program. Our records show that you are receiving
employment support from MARYLAND EMPLOYMENT NETWORK. We must
decide if you are making the required progress toward your vocational goals.
To do this, we look at whether you are completing educational requirements,
and getting and keeping a job.

*0401Z08AB000038*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðôðñéðøÁÂððððóø\

Important Information

Page 2 of 8

For general questions about Social Security benefits, please visit Social
Security's website at http://www.socialsecurity.gov. You also may call Social
Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778), or you may write or
visit any Social Security office. They also can give you information about
other employment supports that help people with disabilities go to work. If
you visit a Social Security office, please take this letter with you.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the
Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

Enclosures:
Timely Progress Review Chart
Privacy Act and Paperwork Reduction Act
Progress Review Form SSA-1375
BRM Envelope ICN-588913

Page 3 of 8

Review Period: You must achieve at least one of the requirements listed
for your particular review period before we find that you have made
timely progress for that review period.    The review period is at least twelve
months long, and there is usually one review a year. In the list below, the
"Trial Work Level Amount" for 2015 is $780. The "Substantial Gainful Activity
Amount" for 2015 is $1,090. These amounts can increase slightly each year.
_________________________________________________________________

Third Review
 •     9 months of work at or above the substantial gainful activity amount;
  OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Complete a 2-year college program and earn a degree or certificate; OR
 •     Complete a technical, trade, or vocational training program.
_________________________________________________________________
Fourth Review
 •     9 months of work at or above the substantial gainful activity amount;
  OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education
  requirements.
_________________________________________________________________

0026010635600612018021235000101

Second Review
 •     6 months of work at or above the trial work level amount; OR
 •     Complete at least 75% of a full-time course load for an academic year
  in a 2-year or 4-year college or a technical, trade, or vocational training
  program; OR
 •     Complete a combination* of the above work and education
  requirements.
_________________________________________________________________

000000000

First Review
 •     3 months of work at or above the trial work level amount; OR
 •     Complete at least 60% of a full-time course load for an academic year
  in a 2-year or 4-year college or a technical, trade, or vocational training
  program; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Obtain a GED or high school diploma.
_________________________________________________________________

*0402Z08AB000038*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðôðòéðøÁÂððððóø\

Timely Progress Review Chart

Page 4 of 8

Fifth Review
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of Social Security Disability Insurance (SSDI) and
  Federal Supplemental Security Income (SSI) cash benefits; OR
 •     Complete a full-time academic year of study at a 4-year college; OR
 •     Complete a combination* of the above work and education requirements;
  OR
 •     Complete a 4-year college program and earn a degree or certificate.
_________________________________________________________________
Sixth Review
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of SSDI and Federal SSI cash benefits; OR
 •     Complete a 4-year college program and earn a degree or certificate.
_________________________________________________________________
Seventh Review and Any Additional Reviews
 •     6 months of work and have earnings in each of those 6 months that
  prevent payment of SSDI and Federal SSI cash benefits.
* A "combination" means you can complete part of the work and part of the
education requirements. We will count the parts you complete as percentages.
Adding the two percentages together must equal 100% or more.

Page 5 of 8

CollectionŽandŽUseŽofŽPersonalŽInformation

See Revised Privacy Act
Statement Attached

Public Law 106-170 and Section 1148 of the Social Security Act, as amended,
authorize us to collect this information. We will use the information you
provide to determine if you have met the progress review requirements for the
Ticket to Work program.
Furnishing us this information is voluntary. However, failing to provide us
with all or part of the information may prevent review of your progress. In
order to be able to pass the progress review and remain excused from a medical
review, you should answer the questions on this form.

 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 our records (e.g., to the Government Accountability Office and
 Department of Veterans 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 and improvement of our programs
 (e.g., to the Bureau of the Census and to private entities under
 contract with us).

We may share the information you provide with other health agencies through
computer matching programs. Matching programs compare our records with
records kept by other Federal, State, or local government agencies. We use the
information from these programs to establish or verify a person's eligibility for
Federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
A complete list of when we may share your information with others, called
routine uses, is available in our Privacy Act Systems of Records Notices
entitled Electronic Disability (eDib) Claim File (60-0320); Ticket-to-Work and
Self-Sufficiency Program Payment Database (60-0295); and Ticket-to-Work
Program Manager (PM) Management Information System (60-0300). Additional
information about these and other systems of records notices and our programs
is available from our Internet website at www.socialsecurity.gov or at your
local Social Security office.

0026010635600612018021235000101

 1.

000000000

We rarely use the information you supply for any purpose other than your
progress review requirements under the Ticket to Work program. However, we
may use the information for the administration of our programs including
sharing information:

*0403Z08AB000038*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

\ðôðóéðøÁÂððððóø\

   Privacy Act Statement

Page 6 of 8

  PaperworkŽReductionŽActŽNotice

This information collection meets the requirements of 44 U.S.C. section 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 15 minutes to
read the instructions, gather the facts, and answer the questions. 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.

Page 7 of 8

Form SSA-1375, OMB approved No. 0960-0644
_________________________________________________________________
Progress Review Form, 7th Review
RETURN THIS PAGE to Social Security, Ticket to Work
Beneficiary: JANE DOE
Social Security Number: 123-45-6789
 TW01
Provider: MARYLAND EMPLOYMENT NETWORK
Date: July 31, 2015
Your Review Period: From December 10, 2014 through December 10, 2014

*Amount represents the full Substantial Gainful Activity amount. This amount
can increase slightly each year.
 Sign and date this form and mail or fax back to us.

I understand that if I make, or cause to be made, a representation concerning
the requirements of the Ticket to Work and Self-Sufficiency Program which I
know is false, I could be punished by fine, or imprisonment, or both.
____________________________________
Signature

  ______________________________

Date

Return this form SSA-1375 to Ticket to Work within 30 days   using the
enclosed postage-paid envelope or by fax at 1-703-893-4020. Our return address
is:
Ticket to Work
Social Security Administration

0026010635600612018021235000101

1. I worked at least six months of the review period with gross earnings at or
above $1070.00 * in each of these months, and for these same months did not
receive payment of cash benefits from Social Security Disability Insurance
(SSDI) and Federal Supplemental Security Income (SSI).
______ Yes
  ______ No
_________________________________________________________________

000000000

INSTRUCTIONS:    Please inform us of your progress for your review period
shown above by completing the items below on all remaining pages of this form
SSA-1375. Check "Yes" or "No" for each item and where you check "Yes"
provide any requested information on progress with work and earnings,
education, or technical training. Then sign, date, and return all pages of this
form SSA-1375 to Ticket to Work using the enclosed postage-paid envelope or
by fax at 1-703-893-4020.    It is important that you respond within 30 days of
the date on this form.   You may keep a copy of this form for your records.
_________________________________________________________________

*0404Z08AB000038*NOTAFP.X3.PBZ08ORS.TOP.R15TEST.PAM

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Social Security Administration

Page 8 of 8

P.O. Box 1433
Alexandria, VA 22313
Form SSA-1375, Progress Review Form, 7th Review
Beneficiary: JANE DOE
Social Security Number: 123-45-6789
   TW01
RETURN THIS PAGE to Social Security, Ticket to Work

SSA will insert the following revised Privacy Act Statement 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 assigning those ticket holders to your Employment Network
(EN).
We will use the information to assign participants in the Ticket to Work and Self-Sufficiency
Program to your EN. 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.

EN Ticket Assignment Request Form
File Type	application/pdf
Subject	No Subject
Author	No Author
File Modified	2018-11-05
File Created	2015-08-10