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State Agency Ticket Assignment Form Ticket To Work And Self-Sufficiency Program

Download and Print the SSA-1365

Request may not be processed if the form is incomplete or illegible.

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 under an EN payment system. 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. If the ticket has never been assigned, this form must be accompanied by the 18-month prior earnings look-back information. 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 ATTN: Ticket Assignment P.O. Box 25105 Alexandria, VA 22313
Fax - 703-893-4149
A. To be Completed by State VR Agency (after verifying the beneficiary has a ticket which may be assigned to the State VR agency)
1. Enter the State VR Agency's name
Enter the State VR Agency's Data Universal Numbering System (DUNS).

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) What is the expected type of job? (Check one EEOC classification below):
Executive/Managerial - Technical/Paraprofessional - Service Worker - Other Professional - Skilled  Craft - Operative Sales - Secretarial/Office/Clerical - Laborer

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)

6. In the Individualized Plan for Employment, date established for meeting the vocational objective chosen (month, year)

7. Please describe the services and supports to be provided to the beneficiary to accomplish the vocational goal in 4 above and help the beneficiary's progress toward self-sufficiency:
a. Service during initial job acquisition and retention phase, i.e. services you plan to complete by the time the Phase 1, Milestone 4 payment is requested (9 months of work attained)
b. Other services during ongoing support phases.

And much more...