Form SSA-1365 State Agency Ticket Assignment Form

Form SSA-1365 (04-2016)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0644

STATE AGENCY TICKET ASSIGNMENT FORM
TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM
Instructions - This form must be completed to record that a beneficiary who is a ticket holder has decided to assign the ticket to
a State Vocational Rehabilitation (VR) Agency under an EN payment system. The form must be completed by both the State VR
agency representative and the ticket holder or, as appropriate, the ticket holder's representative. The State VR agency will submit
this form in lieu of submitting the Individualized Plan for Employment. If the ticket has never been assigned, this form must be
accompanied by the 18-month prior earnings look-back information. The ticket holder or his/her representative, as appropriate
must sign this form to confirm the decision to assign the ticket to the State VR agency. The State VR agency will either send or
fax the completed and signed form to:
Mail : Ticket to Work
Attn: Ticket Assignment
P.O. Box 1433
Alexandria, VA 22313

Fax - 703-893-4149

A. To be Completed by State VR Agency (after verifying the beneficiary has a ticket which may be assigned to the State
VR agency)
1. Enter the State VR Agency's name
Enter the State VR Agency's Data Universal Numbering
System (DUNS).
2. Ticket Holder's Name (Last, First, Middle Initial)

3. Ticket Holder Number (This is the Social Security Number on
the ticket with the TW suffix).
TW

4. (a) What vocational objective or employment outcome is outlined in the ticket holder's Individualized Plan for Employment?
(b) What is the expected type of job? (Check one EEOC classification below):
Executive/Managerial
Technical/Paraprofessional
Service Worker
Other
Operative
Professional
Skilled Craft
Sales
Secretarial/Office/Clerical
Laborer
5. (a) Date the individualized Plan for Employment was signed 5. (b) Date the Individualized Plan for Employment was signed
by ticket holder or his/her representative (month, day, year)
by the State VR agency counselor (month, day, year)
6. In the Individualized Plan for Employment, date established for meeting the vocational objective chosen (month, year)
7. Please describe the services and supports to be provided to the beneficiary to accomplish the vocational goal in 4 above and
help the beneficiary's progress toward self-sufficiency:
a. Service during initial job acquisition and retention phase, i.e. services you plan to complete by the time the Phase 1,
Milestone 4 payment is requested (9 months of work attained)

b. Other services during ongoing support phases.

Form SSA-1365 (04-2016)

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B. To be completed by the ticket holder or ticket holder's representative

Check the appropriate box and sign your name in the space provided below.
I am the ticket holder to whom the information on this form applies.
I am the representative of the ticket holder to whom the information on this form applies and am acting on his/her behalf.
I understand that once my ticket is assigned to the State VR agency, I have the right to retrieve my ticket for any reason. I
acknowledge that the information contained on this form relating to the ticket holder is correct, and that I do willingly agree to
assign my ticket to the State VR agency shown above.
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements
or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false statement
about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a fine
or imprisonment.
Ticket Holder or Representative Signature

DATE

State VR Agency Representative Signature

DATE

Privacy Act Statement
Collection and Use of Personal Information
Section 1148 of the Social Security Act authorizes us to collect this information. We will use the information to assign your
ticket to your selected provider and to monitor your progress in the Ticket to Work and Self-Sufficiency Program.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from
assigning your ticket to your chosen provider.
We rarely use the information you supply for any purpose other than what we state above, however, we may use the information
for the administration of our programs including sharing information:
1.

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); and,

2.

To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract with us).

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

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by
section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of
Management and Budget control number. We estimate that it will take about 3 minutes to read the instructions, gather the facts,
and answer the questions. SEND THE COMPLETED FORM TO: TICKET TO WORK, Attn: Ticket Assignment, PO BOX 1433,
ALEXANDRIA, VA 22313 OR FAX TO 703-893-4149. You may send comments on our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.