Form SSA-1391 Employment Network Payment Request Form

Form Approved
OMB No. 0960-0644

SOCIAL SECURITY ADMINISTRATION

Employment Network Payment Request Form
This form may be used to request Evidentiary Payment Requests (EPRs)
To Ensure Prompt and Accurate Payment to Your Employment Network, Please Complete the
Following Form And Attach Any Acceptable Earnings Information Required
I. Employment Network Information
EN Organization Name:
PID Number:
Is the financial institution and bank account information provided to SAM.GOV current?
No

(if no, please contact SAM @ 1-866-606-8220 before submitting this request)

Incorrect Or Outdated Information May Delay or
Prevent Payment Issuance to Your Employment Network
II. Ticketholder Information
Ticketholder's Name:
Ticket Number/Social Security Number:
Name of Ticketholder's Employer:
Employer's Address (if available):
Payment method for this Ticket Assignment:
Outcome Payment Method

Milestone-Outcome Payment Method

III. Phase 1 Milestone 1 Earnings Information
Select one option only if requesting a Phase I Milestone 1 payment.
Ticketholder achieved Trail Work Level (TWL) earnings during the calendar claim month.
Ticketholder achieved less than TWL but expects to achieve TWL earnings within the next 2
months.

Form SSA-1391 (02-2013)

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Form Approved
OMB No. 0960-0644

SOCIAL SECURITY ADMINISTRATION

IV. Payment Request Details
Payment Request Type
A. Evidentiary Payment Request Claim month(s) and year(s) for this payment request:
Proof of Relationship Details
If requesting Phase 1 Milestone 1, 2 or 3, in the table below describe in detail the services provided with
the date the services were provided during the Milestone period.
Milestone Payment

Date of Service

Description of Services

P1M-1
P1M-2
P1M-3
V.

Evidentiary Earnings Information

Type of earnings documentation submitted: (these items must be included with this form)
Pay Slips
Employer prepared and signed employee earnings statement
The Work Number

http://www.theworknumber.com/

**If submitting a signed Employer Prepared Earnings Statement or The Work Number Report, proof of relationship is
required.
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.

VI. Repayment Agreement (signature required):
By signing below, you as the EN agree to repay any payments received (or allow the amount to be deducted from
future payments) if it is determined at a later date that you were not entitled to payment.

Signature:

Form SSA-1391 (02-2013)

Date:

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VII. Contact Information for the Employment Network Representative Submitting this Request
PRINT NAME:
PHONE NUMBER:
FAX:

EMAIL:

Privacy Act Statement
Collection and Use of Personal Information
Section 1148, of the Social Security Act, as amended, authorizes us to collect this information. The
information is needed to permit the Social Security Administration (SSA) to verify eligibility for payment.
The information you furnish on this form is voluntary. However, failure to provide all or part of the information
requested on this form could prevent you from receiving payment.
We rarely use the information you supply for any purpose other than for monitoring the progress of a participant
in the Ticket to Work and Self Sufficiency Program. However, we may use it for the administration and integrity
of Social Security programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to:
(1)

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 Social
Security records (e.g., to the Government Accountability Office and Department of
Veteran 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 of Social Security programs.

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 and administered
benefit programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Record Notices 60-0295 and
60-0300. The notices, additional information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.

Form SSA-1391 (02-2013)

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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, PO BOX 1433, ALEXANDRIA, VA 22313 OR FAX TO 703-893-4020. 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-1391 (02-2013)

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