Form Approved OMB No. 0960-0641 67$7( $*(1&< 7,&.(7 $66,*10(17 )250 7,&.(7 72 :25. $1' 6(/) 68)),&,(1&< 352*5$0 Instructions - This form must be completed to record that a beneficiary who is a ticket holder has decided to assign the ticket to a State Vocational Rehabilitation (VR) Agency. The form must be completed by both the State VR agency representative and the ticket holder or, as appropriate, the ticket holder's representative. The State VR agency will submit this form in lieu of submitting the Individualized Plan for Employment. The ticket holder or his/her representative, as appropriate must sign this form to confirm the decision to assign the ticket to the State VR agency. The State VR agency will either send or fax the completed and signed form to: Mail - MAXIMUS Ticket to Work Fax - 703-683-3289 ATTN: Ticket Assignment P.O. Box 25105 Alexandria, VA 22313 A. To be Completed by State VR Agency (after verifying the beneficiary has a ticket which may be assigned o the State VR agency) 1. Enter the State VR Agency's name Enter the State VR Agency's Employer Identification Number (EIN) 2. Ticket Holder's Name (Last, First, Middle Initial) 3. Ticket Holder Number (This is the Social Security Number on the ticket with the TW suffix.) TW 4. (a) What vocational objective or employment outcome is outlined in the ticket holder's Individualized Plan for Employment? B. To be completed by the ticket holder or ticket holder's representative Check the appropriate box and sign your name in the space provided below. Form 66$ 6. In the Individualized Plan for Employment, date established for meeting the vocational objective chosen (month, year) Executive/Managerial Skilled Craft Laborer Professional Secretarial/Office/Clerical Sales Service Worker Technical/Paraprofessional Operative (b) What is the expected type of job? (Check one EEOC classification below): 5. (a) Date the Individualized Plan for Employment was signed by ticket holder or his/her representative (month, day, year) 5. (b) Date the Individualized Plan for Employment was signed by the State VR agency counselor (month, day, year) 7. What SSA Payment system is the State VR agency selecting with respect to this ticket holder? ( Place an X in the appropriate box.) Cost Reimbursement Payment System State VR agency's employment network payment system of record (If this option is selected, submit Form SSA-1366, "State Vocational Rehabilitation Ticket to Work Information Sheet" or equivalent information with this SSA-1365) I am the ticket holder to whom the information on this form applies. I am the representative of the ticket holder to whom the information on this form applies and am acting on his/her behalf. Date Date Ticket Holder or Representative Signature State VR Agency Representative Signature I understand that once my ticket is assigned to the State VR agency, I have the right to retrieve my ticket for any reason. I acknowledge that the information contained on this form relating to the ticket holder is correct, and that I do willingly agree to assign my ticket to the State VR agency shown above. 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 a fine, or imprisonment, or both. Paperwork Reduction Act Notice The Social Security Administration is authorized to collect the information on this form under Public Law 106-170 and section 1148 of the Social Security Act. While furnishing the information on this form is voluntary, failure to provide all or part of the information on this form to the Social Security Administration will prevent assignment of your Ticket to Work to the provider of services chosen by you. The information provided on this form will allow the Social Security Administration to monitor the progress of a participant in the Ticket to Work and Self-Sufficiency Program. Although the information you furnish on this form is almost never used for any other purposes than stated in the foregoing, there is a possibility that for the administration of the Social Security programs or for the administration of programs requiring coordination with the Social Security Administration, information may be disclosed to another person or to another government agency as follows: (1) to another Federal, State, or local government agency for determining eligibility for a government benefit or program; (2) to a Congressional office requesting information on behalf of the program participant; (3) to a third party for the performance of research and statistical activities; and (4) to the Department of Justice for use in representing the Federal Government. The information you provide may also be used without your consent in automated matching programs. These matching program are computer comparisons of Social Security Administration records with records kept by other Federal agencies or State and local government agencies. Information from these matching programs can be used to establish or verify a person's eligibility for federally funded or administered benefit programs and for repayment of payments or delinquent debts under these programs. We may also use this information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it. Explanations about these and other reasons why information you provide may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office. We are required by law to notify you that this information collection is in accordance with the clearance requirements of 44 U.S.C. §3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid Office of Management and Budget control number. We estimate that it will take you about 3 minutes to complete this form. This includes the time it takes to read the instructions, gather the necessary facts, and answer the questions. Collection and Use of Information from Your Ticket Assignment Form Privacy Act Statement