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: EN Change Form (PDF)
  • Form 222: Security Awareness - Contractor Personnel Security Certification (PDF)
  • EN Change Form (Section Three) (DOC) (PDF)
  • EN Termination Form (PDF) (DOC)

Suitability

  • e-QIP Paperwork Coversheet (DOC) Updated!
  • e-QIP Applicant Listing (DOC)
  • Standard Form 85 (PDF)
  • Fair Credit Authorization Form (PDF) Updated!
  • Declaration for Federal Employment (PDF)

Ticket Assignment

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) Updated!
  • Ticket Assignment Request (PDF)

Payments

  • Form 1373: EN Supplemental Earnings Statement (PDF)
  • Form 1391: EN Payment Request Form (PDF)
  • Form 1401: EN Split Payment Request Form (PDF)
  • EN Services Certification Statement (DOC) New!
  • Employer-Prepared Earnings Statement (PDF)