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Registration - Step 1

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 *

Tell us about your disability:

Best Time To Contact

Date of Birth: *

Email Address: *

Phone: *

SSI Amount:

SSDI Amount:

Married: *

Yes No

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

Click Here to Sign

Ticket to Work

Individual Work Plan
Please read the following information and sign the acknowledgement below

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.
Will provide contact information for 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 5^th 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)	1^st 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 https://choosework.ssa.gov/, 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 Incentive. 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.
Keep disABLEd WORKERS LLC and his/her local SSA field office updated by sending copies of wages and/or stubs as received and/or requested.
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.

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.

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.
The 5-digit zip code and 10-digit phone number you have provided will be associated with this card to be used for activation.

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: