Application

Step 1

Please complete the next step following the submission of this form.

This page only gives us information about your situation so that we can answer your questions. We will not sign your forms until after we have completed a processing appointment with you and you agree to sign up for our services.

Social Security offers you support to work, go to school, or even start your own business. Some are new and some of the old ones have been revised. We hope to provide you with a wide variety of choices (including the PASS Plan & Ticket to Work) to help you make an informed decision on how you are going to live your life.

 

Filling out forms is a pain, but the more information and personal thoughts that you can share with us the better we can help you.

First Name *
Middle name *
Last name *
Primary Language
Gender *
Address *
Apt#
City *
State *
Zip Code *
Best Time To Contact
How Did You Hear About Us?
Are you a Veteran?
Select those that pertain to your situation
Tell us about your disability *
Are your SSA benefits based on legal blindness? *
Do you use any assistive devices, such as wheelchair, braille,etc. Please List
Marital Information
Marital Status *
Optional information
Have you ever been convicted of a Felony? (This answer is completely voluntary and does not affect your application in any way)

 

EN: disABLEd WORKERS LLC
2715 Terrace Dr.
Cedar Falls, IA 50613
Ph: (319) 215-4543
Fax: (888) 504-7957
Toll free: (877) 291-9806
DUNS#: 139944404
Ticket to Work
Individual Work Plan
Ticket-Holders's Name: ( Please Enter First and Last Name with no spaces or special characters. Ex: JoeSmith)
Address: Married: Yes
No
City: Date of Birth:
State: Zip:
Phone: SSI Amount:
Alternate Contact: SSDI Amount:
Email Address:

You must state a type of work, or a job title in both!
3-12 Month Job Type: Projected Wage: $
Type in what job you want to do, or want to do while you are retraining. Please be SPECIFIC.

3-5 Year Job Type: Projected Wage: $
Type in what job you want to do after your training. If you don't want or need training, enter in the same answer..
To reach your 3 to 5 year goal do you need further training or education? (Yes or No):
How long will that training take? (Estimate):

Services & Supports Provided by disABLEd WORKERS LLC to all clients:
  • Help in understanding different Social Security Work support payments and how they will affect benefits received. Including help with keeping track of TWP months, EPE, and Extended Medicare as long as wages are reported.
  • Referrals to other agencies, if needed.
  • Continuing employment supports (quarterly at a minimum) to assess employment needs.
  • Provide with job search assistance as needed, or as available.
  • While your Ticket is assigned,active, and meeting Timely progress you will not be subject to medical review.
  • disABLEd WORKERS LLC has informed me of the annual progress reports and timely review guidelines, as shown below.

12-month review period

Work Requirement

Degree or Certification Program

Technical, Trade or Vocational Program

First year

3 out of 12 months with trial work period level (TWL) earnings.

Completed 60% of full time course load for 1 year.

Completed 60% of full time course load for 1 year.

Second year

6 out of 12 months with trial work period level (TWL) earnings.

Completed 75% of full time course load for 1 year.

Completed 75% of full time course load for 1 year.

Third year

9 out of 12 months with substantial gainful activity (SGA) level earnings.

Completed a 2-year program or, for a 4-year program, an additional academic year of full time study.

Completed the program.

Fourth year

9 out of 12 months with substantial gainful activity (SGA) level earnings.

Completed an additional academic year of full time study.

 

Fifth year

6 out of 12 months with substantial gainful activity (SGA) level earnings with no SSDI or SSI benefits.

Completed an additional academic year of full time study.

 

Sixth year

Work criteria are same for 5th and subsequent 12-month period.

Completed a 4-year degree program.

 

 

  • Beneficiaries may receive, if available and the requirements are met according to Social Security’s rules, the following support payments for work support related expenses. No payments are a guarantee.

 

Amount of the support payment

Projected time of qualification

Costs and Descriptions of Employment Related Services Needed to Reach Agreed Employment Goal.

$500 (SSI, SSDI or Concurrent recipients)

1st month at TWL after month of Assignment

 

$500 (SSI, SSDI or Concurrent recipients)

3 out of 6 months at TWL.

 

$500 (SSI, SSDI or Concurrent recipients)

6 out of 12 months at TWL.

 

$500 (SSI, SSDI or Concurrent recipients)

9 out of 18 months at TWL.

 

3 x $100 (SSI recipients)

Months at SGA level and receiving benefits.

 

3 x $200 (SSDI or Concurrent recipients)

Months at SGA level and receiving benefits.

 

60 x $100 (SSI recipients)

Months at SSI cap level and not receiving benefits.

 

36 x $200 (SSDI or Concurrent recipients)

Months at SGA level and not receiving benefits.

 

 

  • disABLEdWORKERS LLC agrees to not request or receive any compensation for the cost of basic Ticket to Work services provided to the beneficiary while Ticket is assigned to EN.
  • disABLEdWORKERS LLC may offer me additional services, that are not TTW related, at any time, and that those services may cost additional fees. All additional fees will be explicitly agreed to on a supplemental agreement.
  • disABLEdWORKERS LLC has the right to terminate this agreement at any time for any reason, with no notice to the Ticket-Holder.
  • Ticket-holder and disABLEd WORKERS LLC have the right to amend this if both parties agree to the changes.
  • Ticket-holder has the right to unassign their Ticket at any time if the Ticket-holder is dissatisfied with the services being provided.
  • If Ticket-holder has a dispute with disABLEd WORKERS LLC, they may seek remedy from MAXIMUS, INC, after good faith attempts to resolve concerns with disABLEd WORKERS LLC. Their site can be found at www.chooseworkttw.net, or by calling toll free 1-866-968-7842.
  • disABLEdWORKERS LLC will maintain Ticket-holders rights to privacy and confidentiality regarding personal information, including Social Security Number and information about beneficiarys disability.
  • disABLEdWORKERS LLC does not provide any PASS Plan funding. The PASS is a Social Security work support payment. disABLEdWORKERS LLC cannot be held liable for any expected funding if the Social Security PASS Plan is not approved.
  • Ticket-holder has the right to a copy of this IWP in a format that is accessible to them.
  • Only qualified employees and/or providers will be used to furnish services to Ticket-holder.
  • No medical or health related services are provided by disABLEd WORKERS LLC.
  • disABLEdWORKERS LLC makes no representations or guarantees about job positions, and is not responsible for safety, wages, working conditions, or other aspects of employment. It is the responsibility of the Ticket-Holder to research the integrity of the organizations to which they are applying. The individual is advised to use caution and reasonable judgement when applying for any position with an organization or a private party. You should not go alone to a residential address to apply for a job. Do not put yourself in a vulnerable position. Even the best job opportunity is not worth jeopardizing your personal safety.
  • disABLEdWORKERS LLC sends job leads containing links to web sites not under our control, and we are not responsible for the contents of any linked site. disABLEd WORKERS LLC assumes no liability for acts of omissions by third parties or for material supplied by them.
  • disABLEd WORKERS LLC functions under a CDS business model with the SSA by providing TTW holders with a managed spend card for direct purchase of support services.
  • disABLEd WORKERS LLC does not provide job accommodations or on site job coaching.

Ticket-Holders responsibilities, rights, and agrees to:
  • Report any changes in employment or residence within 10 days to disABLEd WORKERS LLC.
  • Update by sending copies of wages and/or stubs as received, or as requested by disABLEd WORKERS LLC.
  • Will try their best to work and see how it affects their disability.

Statement of Understanding: I choose to participate in the Ticket to Work program with disABLED WORKERS LLC. I understand that disABLED WORKERS LLC will provide me with employment support to find and keep a job and increase my earnings to be at, or above SGA, if possible, I plan on increasing my earnings to support myself. I understand that together, we can modify this plan from time to time to meet my changing needs. I acknowledge that upon approval of the IWP by me (the beneficiary) and the EN (disABLED WORKERS), my ticket will be assigned to disABLED WORKERS LLC. By signing this contract I verify that I have read, understand, and agree with all of the terms of this contract, and that I affirm that all of the information included is accurate to the best of my knowledge.

 

Signature of Ticket holder: Date:

                                                                            Please sign below as well.

I authorize my employer to release any and all employment information regarting my wages (ex.,copies of pay stubs etc,) to any representative of disABLEd WORKERS LLC who request this infomation. By signing below, I give my consent to the release of this infomation. This authorization is valid for a 5 year period.

Signature of Ticket holder: Date:

Due to changes in the Social Security Administration's rules, Disabled Workers LLC is improving the method we use to issue support payments to our beneficiaries. Your signature below is verification that you have read this agreement and agree to comply with it.
Agreement to Accept the U.S. Bank VISA One Card with Disabled Workers LLC.
  • I understand the card is for approved purchases only.
  • Improper use of this card can be considered misappropriation of funds. This may result in loss of benefit, as we report any unapproved use to the Social Security Administration.
  • If the card is lost or stolen, I will immediately notify Disabled Workers LLC by telephone.
  • I agree to surrender the card immediately upon termination of my ticket with Disabled Workers LLC.
  • I will not allow any other person to use the card. I am considered responsible for any and all use of the card.
  • As the card is Disabled Workers LLC property, I understand that I may be periodically required to comply with internal control procedures designed to protect company assets. This may include being asked to produce receipts and statements to audit its use.
  • I will receive a Monthly Reconciliation Statement (MRS), which will report all activity during the statement period. I will contact Disabled Workers LLC to resolve any discrepancies.
  • I understand that the US Bank VISA ONE card is not necessarily provided to all clients. Assignment is based on my need to purchase materials for educational or employment related expenses. My card may be revoked based on change of assignment.
  • I agree that the card and funds I am issued will only be used for educational or employment related expenses for me and not my family or anyone else.
  • No support payments to the beneficiary will be issued until this contract is signed and received.
  • Please indicate the 5-digit zip code and 10-digit phone number you want associated with this card to be used for activation.

    Zip Code:

    Phone:
    (Please Enter Just The Phone Number No Dashes)

  • Please indicate the address where you would like the card mailed if and when it is issued. Be sure to update us with any new address, phone number or email address.

    Street Address: City:
    State:  
    Name as you would like it to appear on your card:
Ticket Holder Signature: Date:

Work History:

 

  I am currently working.

  I had no earnings in the last 18 months.

  I had some earnings in the last 18 months

Please give information about where you have worked in the last 18 months. Estimates to the best of your ability are fine. If you have pay stubs, even better. This information is needed for us to be able to determine where you are at in your Trial Work Period.
Company Name Date started Date Ended Hourly Wage Hours worked Per week

Social Security Administration                                                              Form Approved

Consent for Release of Information                                                        OMB No. 0960-0566

 

You must complete all required fields. We will not honor your request unless all required fields are completed. (*signifies a required field).

TO: Social Security Administration

Claimant Name: Date Of Birth:

I authorize the Social Security Administration to release information or records about me to:

*NAME OF PERSON OR ORGANIZATION:

Disabled Workers LLC

*ADDRESS OF PERSON OR ORGANIZATION:

2715 Terrace Dr. Cedar Falls, IA 50613

 

*I want this information released because:

We may charge a fee to release information for non-program purposes.

To be used to assist in Social Security work incentive benefit analysis.

 

*Please release the following information selected from the list below:

 

You must specify the records you are requesting by checking at least one box. We will not honor a request for "any and all records" or "my entire file." Also, we will not disclose records unless you include the applicable date ranges where requested.

 

  1. Social Security Number
  2. Current monthly Social Security benefit amount
  3. Current monthly Supplemental Security Income payment amount
  4. My benefit or payment amounts from date __________ to date________
  5. My Medicare entitlement from date  __________ to date________
  6. Medical records from my claims folder(s) from date  __________ to date________                                         If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social Security office. 
  7. Complete medical records from my claims folder(s)
  8. Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application, determination or questionnaire)

BPQY, Monthly Earnings Statement

 

I am the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or the legal guardian of a legally incompetent adult. I declare under penalty of perjury (28 CFR § 16.41(d)(2004)) that I have examined all the information on this form, and any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly or willfully seeks or obtain access to records about another person under false pretenses is punishable by a fine of up to $5,000. I also understand that I must pay all applicable fees for requesting information for a non-program-related purpose.

 

* Signature: Date:
*Address: Phone:
Relationship (if not the subject of the record)

Witnesses must sign this form ONLY if the above signature is by mark (X). If signed by mark (X), two witnesses to the signing who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the signature line above.

1.Signature of witness

2.Signature of witness

N/A

N/A

 

 

Address(Number and street,City,State, and Zip Code)

Address(Number and street,City,State, and Zip Code)

 

 

Form SSA-3288 (07-2013) EF (07-2013)

 



Social Security Administration
Request for Social Security Earnings Information
TO: Social Security Administration

Claimant Name: Date Of Birth:

I authorize the Social Security Administration to release information or records about me to:
PASSPLANHELP % disABLEd WORKERS
Stefanie Steies
2715 Terrace Dr
Cedar Falls, IA 50613
Phone: (319) 215-4543
Fax: (888) 504-7957
email: support@disabledworkersusa.com
I want this information released:
    To be used to assist in a Social Security work support payment benefit analysis.
Please release the following information:
Please provide the total earnings credited to my record by my employer(s) for the following XXX   All Taxable calendar years to present
I am the individual to whom the information/record applies or that person's parent (if a minor) or legal guardian. I know that if I make any representation, which I know is false to obtain information from Social Security records, I could be punished by a fine or imprisonment or both.
I understand that this authorization of release of information shall expire one year from the date it is signed. I understand that I may cancel this consent at any time by submitting a written request to Social Security and that any cancellation will not affect the information already released.
Claimant Signature: Date:
Phone: Email:
DUNS#: 139944404
Agency Representative Stefanie Steies
EN Representative