Forms

Current Employment Networks (EN) and State Vocational Rehabilitation (VR) agencies must submit various forms to the Social Security Administration and the Ticket Program Manager. For questions about a specific form, use the contact information located on the form.

Maintenance

  • Form 1374: Ticket Program Agreement (TPA) Change Form (PDF) New!
  • Form 222: Security Awareness - Contractor Personnel Security Certification (PDF)
  • Form 222: Security Awareness Addendum - Contractor Personnel Security Certification (PDF) New!
  • Ticket Program Agreement (TPA) Termination Form (PDF) New!

Suitability

  • EN Personnel Suitability Cover Sheet (PDF) Updated!
  • eAPP Applicant Listing (XLS) Updated!
  • Contractor Personnel Rollover Request Form (PDF) New!  Updated!
  • Fingerprint Scheduling Instructions (PDF) New!  Updated!
  • I-9 Approved Documents (PDF) New!  Updated!
  • Standard Form 85 (PDF)
  • Fair Credit Authorization Form (PDF)
  • Declaration for Federal Employment OF-306 (PDF)

Services and Supports

Form SSA – 1370 is now available for use. The revised form has been submitted to the Office of Management and Budget (OMB) for clearance. In the interim, Social Security is providing the revised document to be used as a guide to help ENs develop IWPs with their Ticket Holders.

  • Form 1370: Individual Work Plan (PDF)
  • EN Certification of Services (COS) Statement (PDF)
  • Telephone Message Documentation (PDF) New!
  • Certified Letter Documentation (PDF) New!

Payments

  • Form 1373: EN Supplemental Earnings Statement (PDF)
  • Form 1391: EN Payment Request Form (PDF)
  • Form 1401: EN Split Payment Request Form (PDF)
  • Employer-Prepared Earnings Statement (PDF)