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					                          MAXIMUS




NEW FORMS AND DOCUMENTS




                                    1
                                 MAXIMUS
         Documents

 • Individual Work Plan (IWP)

• 18-month Prior Earnings Tool

   • Payment Request Form

     • Split Payment Form

• 2010 EN Payments-at-a-Glance

  • EN Contract Change Form
                                           2
                                                            MAXIMUS
                             Acronyms
EN – Employment Network
VR – Vocational Rehabilitation
SSA – Social Security Administration
WIPA – Work Incentive Planning and Assistance Program
TWP – Trial Work Period
TPR – Timely Progress Review
CDR – Continuing Disability Review
EIN – Employer Identification Number
IWP – Individual Work Plan
PII – Personally Identifiable Information
SGA – Substantial Gainful Activity
SSDI – Social Security Disability Insurance (Title II/T2)
SSI – Supplemental Security Income (Title XVI/T16)                    3
                                                                                 MAXIMUS

                               The Individual Work Plan (IWP)
 SOCIAL SECURITY ADMINISTRATION                                   FORM APPROVED OMB NO. 0960-0644

                           Ticket To Work Individual Work Plan

           Beneficiary Name:                  SSN:

           Address:                           Telephone:
                                              Email:

           Employment                         EIN#:
           Network Name:

           Address:                           Telephone:
                                              Email:



1. What Is Your Specific Vocational Goal And Expected Monthly Earnings Amount?

Short Term Goal (in the next 3 to 12 mos.):

Expected Monthly Earnings Amount (in the next 3 to 12 mos.):

Long Term Career Goal (throughout the next 5 years):

Expected Monthly Earnings Amount (throughout the next 5 years):
                                                                                                    4
                                                                                          MAXIMUS
                                                  IWP

2.    What Supports/Services Have You and Your Counselor Agreed Would be Required for You to
      Reach Your Short Term Goal?

During the job search phase and the first nine months of employment:

After your first 9 months on the job (job retention supports and career advancement, if any):

Employer Start Date End Date Wage Per Hour Hours Worked Per Week



3. Work History
Please check all that apply

     I had no earnings in the last 18 months.

     I had some earnings in the last 18 months.

     None of my earnings were in the last 6 months.

   Some of my earnings were in the last 6 months. (Please describe those earnings in the chart
below, listing your most recent employer first.)


                                                                                                    5
                                                                                        MAXIMUS
                                                 IWP
Employer                       Start Date      End Date       Wage Per Hour   Hours Worked Per Week




NOTE to EN: As a convenience, you may attach a completed 18-Month Prior Earnings Worksheet
(available at http://www.yourtickettowork.com/training_2) or just use it for your own information.


4. Terms and Conditions Related to the Provision of Services (If there are no terms and conditions,
then that must be stated):




                                CONSUMER RIGHTS & REMEDIES
                    (Insert EN name in the blanks below, unless otherwise stated)


                             REMAINDER OF IWP IS THE SAME
                                                                                                      6
                                             MAXIMUS
      18 Month Prior Earning Tool
also known as the   18 Month Lookback Tool




                      2010 $720




                                                       7
                                                                                                                MAXIMUS
                                          Payment Request Form


       Sections 1 and II Remain the same…EN Information and Beneficiary Information

III.        Phase 1 - Milestone 1 Earnings Information (Complete only if requesting Phase 1 Milestone 1)

Please choose one of the following options by placing an “X” next to your selection:

___ A. The beneficiary achieved TWL earnings during the calendar claim month.
___ B. The beneficiary achieved less than TWL, but he/she will achieve TWL earnings within the next 2 months.
___ C. The beneficiary achieved less than TWL earnings and is not expected to achieve TWL earnings
            within the next 2 months.



                                 Sections IV, V, VI and VII remain the same.


         VIII.Contact Information for the Employment Network Representative Submitting this Request

         Print Name:

         Phone Number:                                       FAX:

         Email:




                                                                                                                          8
                                                                                             MAXIMUS


                                         Split Payment Form

•If MAXIMUS receives a first payment request for a beneficiary that was previously assigned to another
EN, a letter will be sent to both EN's notifying them of a possible split payment situation, alerting the first
EN that there may be an opportunity for a split payment should they choose to pursue it. If the EN fails to
respond within 30 days, the claim to a split payment will be forfeited.


•A split payment form will be sent to each EN. On that form, MAXIMUS will identify each of the ENs
involved. The ENs can work together to come to a decision for a percentage split of the payments, or
they can choose to allow MAXIMUS and SSA to make that decision based on each organization's service
records.


•If the ENs choose to come to their own decision, they must each sign the Split Payment Form and send
it back to MAXIMUS indicating what the percentage split will be. Or each EN can sign a separate form
and submit them, each indicating the percentage split. These percentages must match. If the
percentages do not match, MAXIMUS and SSA will make the split determination based on service
records.




                                                                                                             9
                                                                                                                        MAXIMUS


                                 Employment Network Split Payment Request Form
    Beneficiary Name:                                                 SSN:
                                                          Employment Networks
    Current EN:                                                                                         Other EN:
    EIN:                                                                                                EIN:
    Contact Name:                                                                                       Contact Name:
    Phone:                                                                                              Phone:

    Other EN:                                                                                           Other EN:
    EIN:                                                                                                EIN:
    Contact Name:                                                                                       Contact Name:
    Phone:                                                                                              Phone:

                                                                 Proposed Payment Split
Please check the box below to indicate which payment split would be most applicable to the relationship amongst the ENs requesting payment.

                        Simple 2 Way Split                                                               Customized Split
                                                                                          Customized Split is only available for 3 or more ENs.
        Please circle the combination associated with the agreed
                            upon percentage split.                                                      Employment        Payment
                    1        2      3      4         5     6     7                                       Network         Percentage

                    100       75    67     50        33    25    0                                  1
        Current                                                                                     2
          EN
                                                                                                    3
       Prior EN         0     25    33     50        67    75   100
                                                                                                    4
                                                                                                                                         10
                                                                                                                                         MAXIMUS




                                                   SSA Determine Split
      Please check the box below to indicate that you would like the PM to determine the split payment percentages.




We have discussed the services provided to the Ticket holder and agree to split the EN payments as requested above.

EN Signature:                                                                                                            Date:

EN Signature:                                                                                                            Date:

EN Signature:                                                                                                            Date:

EN Signature:                                                                                                            Date:
NOTE: The Ticket Program Manager will make the actual determination regarding the allocation of payments to EN’s requesting payment for the same outcome, milestone,
or reconciliation payment under its elected payment system.




                                                                                                                                                              11
                                                    2010 EN Payments-at-a-Glance                                                 MAXIMUS
                                                       OUTCOME PAYMENT METHOD
  Payment            Beneficiary Earnings Required After Ticket                                       SSI Ticket-Holder            SSDI Ticket-Holder
   Type                             Assignment
  Outcome           Earnings sufficient for “zero” cash benefits status                              Up to 60 payments of          Up to 36 payments of
                                                                                                         $409/month                    $711/month
                                    Total of Outcome Payments Available                                     $24,540.                      $25,596.

                                              MILESTONE-OUTCOME PAYMENT METHOD

Payment Type         Beneficiary Earnings Required After Ticket                                      SSI Ticket-Holder            SSDI Ticket-Holder
                                    Assignment
Phase 1
Milestone 1         $360/ month x 1 month                                                                    $1275                         $1275
Milestone 2         $720/ month x 3 months within 6 months                                                   $1275                         $1275
Milestone 3         $720/ month x 6 months within 12 months                                                  $1275                         $1275
Milestone 4         $720/ month x 9 months within 18 months                                                  $1275                         $1275
                                                                   Total for Phase 1                        $5,100                         $5,100
Phase 2
Milestones         Gross earnings at or over $1,000(non-blind)/month                                  Up to 18 payments of         Up to 11 payments of
                   (SGA)                                                                                  $220/ month                  $382/ month
                   Gross earnings at or over $1,640 (blind)/month (SGA)

                                                                               Total for Phase 2             $3,960                       $4,202
                                                    Total Phase 1 + 2 Milestones Payments                    $9,060                       $9,302
Outcome             Earnings sufficient for “zero cash benefit” status                              Up to 60 payments of           Up to 36 payments of
                                                                                                        $220/ month                    $382/ month

                                                    Total of Outcome Payments Available                    $13,200                        $13,752
                                                     Total of Milestones + Outcome Payments                $22,260                        $23,054
 * Milestone payments missed before going to “zero cash benefits” will be given to the EN in a reconciliation payment after 12 Outcome Payments have been
   made.                                                                                                                                               12
                                                                                                               MAXIMUS
                                           EN Contract Change Form
                       Please use this form if you wish to request changes to your Employment Network contract.
                     Simply fill in the applicable information below and submit to MAXIMUS by fax to 703-893-4149.

Please Note: if this form is submitted via email, it must be sent by the named Signatory Authority or Primary Contact identified in
your EN RFP/contract. If this form is faxed, it must be signed by the same.

                If you have any questions, please contact the MAXIMUS Ticket to Work office toll-free at 1-866-949-3687.

                                       Used to Change Information for:

 •Doing Business As (DBA) Name                                        •EN Payment Status Report Information
 •Adding or changing the text field in the EN Directory               •Add, delete, change website
 •Mailing Address                                                     •Type of organization
 •Actual Address                                                      •Add or delete impairment groups
 •Beneficiary Contact Information                                     •Add or delete services offered
 •Primary Contact Information                                         •Add or delete service areas
 •Signatory Authority Information                                     •Add or delete service locations
 •Payment Contact Information                                         •Change to banking information




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Description: PPT Ticket to Work Ticket to Work