SSA-1375 Ticket to Work Progress Review Form

Form Approved
SOCIAL SECURITY ADMINISTRATION

OMB No. 0960-0644

Progress Review Form
Beneficiary:
Provider:

SSN:

Date:

INSTRUCTIONS: Please inform us of your progress during the timeframe shown below by
completing one of the boxes in Sections A-E below. Check “Yes” or “No” and provide
information on progress with work and earnings, education, or technical training when
appropriate to indicate if you have met the first 12-Month Progress Review requirements.
Then sign, date, and return this form to 7,&.(772:25. using the enclosed postage paid
envelope or by fax at 703-683-3289. It is important that you respond within 30 days of the
date on this form. You may retain a copy of this form for your records.

First 12-Month Progress Review Requirements
Between _______________________________ and ____________________________:
A. I worked 3 out of 12 months with earnings at or above $ in each month (Trial
Work Level for 202).
◻Yes ◻No
If Yes, STOP here. Sign and date this form and mail or fax back to us.
OR
B. I obtained a GED or High School Diploma. ◻Yes ◻No
Name of Certifying Agency:_______________________________________________
Agency Address: ________________________________________________________
Date GED or Diploma Earned: _____________________________________________
3,':
SSN:

_________________________________________________________________________
Form SSA-1375

Page 1

If Yes, STOP here. Sign and date this form and mail or fax back to us.

Progress Review Form (continued)
Beneficiary:
Provider:

SSN:

Date:

OR
C. I completed 60% of a full-time course load for a full academic year in a degree or
certification college program.
◻Yes ◻No
School Name: __________________________________________________________
School Address: ________________________________________________________
# Credits Completed:______________ # Credits for full course load:______________
Date Completed:________________________________________________________
If Yes, STOP here. Sign and date this form and mail or fax back to us.
OR
D. I completed 60% of a full-time course load for an academic year in a Technical,
Trade, or Vocational program.
◻Yes ◻No
School Name: __________________________________________________________
School Address: ________________________________________________________
# Credits Completed:______________ # Credits for full course load:______________
Date Completed:________________________________________________________
If Yes, STOP here. Sign and date this form and mail or fax back to us.
OR
E. I completed a combination of earnings PLUS some college degree or certification
credits or technical, trade, or vocational program credits that together equals or
exceeds 100%.
During this period I earned $__________.
AND
I completed _____ credits of a full-time course load in a degree or college
certification program or in a technical, trade, or vocational program.
School Name: __________________________________________________________
3,':
SSN:

_________________________________________________________________________
Form SSA-1375

Page 2

School Address: ________________________________________________________
# Credits for full course load:______________________________________________
Date Completed:________________________________________________________
Sign and date this form and mail or fax back to us.
I declare under penalty of perjury that I have examined all the information on this form,
and on any accompanying statements or forms, and it is true and correct to the best of
my knowledge. I understand that anyone who knowingly gives a false or misleading
statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be sent to prison, or may face other penalties, or both.
I understand that if I make, or cause to be made, a representation which I know is
false concerning the requirements of the Ticket to Work and Self-Sufficiency program,
I could be punished by fine, or imprisonment or both.
_____________________________________
_________________________
Beneficiary Signature
Date
Return this form to 7,&.(772:25. within 30 days using the enclosed postage-paid
envelope or by fax at 703-683-3289.

3,':
SSN:

_________________________________________________________________________
Form SSA-1375

Page 3

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 XX 15
minutes to read the instructions, gather the facts, and answer the questions. SEND THE
COMPLETED FORM TO TICKET TO WORK, PO BOX 1433, ALEXANDRIA, VA
22313, OR FAX TO 703-683-3289. You may send comments on our time estimate above to:
SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our
time estimate to this address, not the completed form.

Form SSA-1375

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 you from pursuing your employment goal under the Ticket to Work
program.
We will use the information to document the requirements towards achieving your employment
goal under the Ticket to Work Program. 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 the Social Security Administration (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.

Form SSA-1375