Proof-of-Relationship-Form

Proof of Relationship (PoR) Form

EN Name:
DUNS Number:
Ticketholder Name:
Ticketholder SSN:
Ticketholder Telephone:
Ticketholder Email:
Ticketholder Address:
Ticket Assignment Date:
Ticket Unassignment Date (if applicable):

Phase 1 Milestone Number (check one):
1

2

3

4

Document Contact and/or Services Provided:
Please list the dates and a description of the contact or services that your EN provided to the
Ticketholder. These services are those agreed upon in the IWP to help the Ticketholder reach
and sustain his or her long-term employment goals since both parties signed the IWP.
Date

Description of Services Provided or Contact

Social Security may verify the information above with the Ticketholder.
By signing below, the EN affirms having provided the services above to the Ticketholder.

EN Representative’s Name

EN Representative’s Signature

Date

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 your ticket to your selected service provider.
We will use the information to monitor your progress in the Ticket to Work and Self
Sufficiency
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 SSA to perform vocational rehabilitation services for

SSA
disability beneficiaries and recipients.
In addition, we may share this information in accordance with the Privacy Act and other
Federal
laws. For example, where authorized, we may use and disclose this information in
computer
matching programs, in which our records are compared with other records to establish
or verify a person’s eligibility for Federal benefit programs and for repayment of
incorrect or delinquent

debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0295, entitled Ticket-to-Work and Self-Sufficiency Program Payment
Database, as published in the Federal Register (FR) on April 4, 2001, at 66 FR 17985 and
60-0300, entitled Ticket-to-Work Program Manager Management Information System, as
published in the FR on June 15, 2001, at 66 FR 32656. Additional information, and a full
listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 10
minutes to read the instructions, gather the facts, and answer the questions. SEND THE
COMPLETED FORM TO: OPERATIONS SUPPORT MANAGER (OSM) TICKET TO WORK,
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.