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

Ticket Assignment

  • Form 1370: Individual Work Plan (PDF)
  • 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)
  • Employer-Prepared Earnings Statement (PDF)