POD Monthly Earnings & IRWE Reporting Form

POD Monthly Earnings & IRWE Reporting Form
Participants in the Promoting Opportunity Demonstration (POD) report their earnings monthly to the POD
project. Participants who have impairment-related work expenses (IRWEs) that exceed the POD
threshold ($840 in 2017) for a given month should also report these expenses. To report your information
electronically, go to: . To report your information by mail or
fax, please provide the information below and complete the four steps listed on this form.

First Name

Last Name
2017

Reporting Month

(

Month and Year of Birth

)

Cell

Home Work (circle one)

Phone Number

Mailing Address (Street, City, State and Zip code)
OR
POD Study ID

Last 4 Digits of Your SSN

Step 1: Collect your paystubs with pay dates paid within the reporting month listed above. If you are
self-employed, please determine or estimate your total profit for the reporting month.
Step 2: List your earnings for the reporting month in the table below, using one line per employer. If you
are self-employed, list the name of the job or business as your employer in the table.
Step 3: Collect the receipts for your IRWEs you paid for in the reporting month. If the sum of your IRWEs
is greater than $840, list your IRWEs in the table below, using one line per IRWE. Please note:
You should not list any IRWEs if your total IRWEs are less than $840 for the reporting month.
Employer name/job or IRWE claimed

Total paid by employer or paid by
you for the IRWE claimed
$
$
$
$
$

Step 4: Return this completed form and documentation (all paystubs paid in the reporting month plus
receipts for IRWE if you are reporting IRWEs greater than $840) to the POD project by: (1) mail

in the enclosed postage-paid envelope; or (2) fax at . Please submit copies
of your documentation, not originals. In order for SSA to process your information timely,
your envelope needs to be postmarked by the 6th of the month following the reporting
month.
Questions? Please contact your POD work incentives counselor or the POD call center at if you have any questions about this form. Note: You can sign up for monthly reminder emails
to report your earnings and IRWEs. To receive monthly reminders, list your email address and sign below
to provide the POD project with consent to email you a reminder each month.
Email:
I give consent for the POD project to email me:
Signature

Date

Privacy Act Statement
Collection and Use of Personal Information

Section 234 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 you
from participating in the Promoting Opportunities Demonstration (POD) project.
We will use the information you provide to manage your participation in the POD project and for
research and statistics purposes. We may also share your information for the following purposes, called
routine uses:
1.

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

2.

To a congressional office in response to an inquiry from that office made at the request of the
subject of a record.

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 for various purposes related to the
agency’s administration of Federal benefit programs, including ensuring proper Federal benefit program
payments.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 600218, entitled Disability Insurance and Supplemental Security Income Demonstration Projects and
Experiments System; 60-0090, entitled Master Beneficiary Record; 60-0103, entitled Supplemental
Security Income Record and Special Veterans Benefits; 60-0094, entitled Recovery of Overpayments,
Accounting, and Reporting, and 60-0330, entitled eWork. Additional information and routine uses, and a
full listing of all our SORNs, are available on our website at www.socialsecurity.gov/foia/bluebook.

Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of
1995. You do not need to answer the survey questions unless we display a valid Office of Management and Budget (OMB) control
number. The OMB control number for this collection is 0960-XXXX; expiration date XX/XX/20XX. We estimate that it will take about 10
minutes to read the instructions, and answer the survey questions. You may send comments about our time estimate to: Social Security
Administration, 6401 Security Blvd, Baltimore, MD 21235-6401