The Ticket to Work and Self-Sufficiency Program

ICR 202401-0960-002

OMB: 0960-0644

Federal Form Document

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0960-0644 can be found here:

2024-04-08 - No material or nonsubstantive change to a currently approved collection

Forms and Documents

Document Name	Status
Form SSA-1370 a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a); 411.465- Individualized Work Plan - SSA-1370 Form and Instruction	Unchanged
Form SSA-1401 f) 20 CFR 411.560 - SSA-1401, Split Payment Situations Form	Unchanged
Form SSA-1394 i) 20 CFR 411.320 - SSA-1374, EN Contract Changes Form and Instruction	Unchanged
Form SSA-1391 f) 20 CFR 411.575 - Requesting EN Payments - SSA-1391; SSA-1398 Form and Instruction	Modified
Form SSA-1375 c) 20 CFR 411.200(b) - SSA-1375 Form	Unchanged
Justification for a Non-Substantive Change 0960-0644.docx Justification for No Material/Nonsubstantive Change	2024-01-18
Supporting Statement - 0644 (Final).docx Supporting Statement A	2022-02-28

IC Document Collections

IC ID	Document Title	Status
9680	a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a); 411.465- Individualized Work Plan - SSA-1370 Form and Instruction	Unchanged
251498	j) 20 CFR 411.200(b) - WISE Webinar Survey Other-Wise Survey	Unchanged
251497	g) 20 CFR 411.325 (f)- Annual Performance Other-Annual Performance Outcome Report	Unchanged
251496	g) 20 CFR 411.325 (f)- Certification of Services	Unchanged
208203	j) 20 CFR 411.200(b) WISE Webinar Registration Page Other-online registration form	Unchanged
201989	a) 20 CFR 411.140(d)(2) - Ticket Assignability - Portal Other-Internet Screens	Unchanged
201988	a) 20 CFR 411.140(d)(2) - Ticket Assignability - IVR Automated Telephone	Unchanged
201837	a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1365 State Agency Ticket Assignment Form Other-screens	Unchanged
190323	f) 20 CFR 411.560 - SSA-1401, Split Payment Situations Form	Unchanged
190204	i) 20 CFR 411.320 - SSA-1374, EN Contract Changes Form and Instruction	Unchanged
184464	h) 20 CFR 411.435, 411.615, 411.625 - Dispute Resolutions	Unchanged
184463	g) 20 CFR 411.325(f) - Proof of Relationship Instruction	Unchanged
184462	f) 20 CFR 411.575 - Requesting EN Payments - SSA-1391; SSA-1398 Form and Instruction	Modified
184461	e) 20 CFR 411.400-411.420, 411.325(d), 411.415 - Reporting Referral Agreement	Unchanged
184460	d) 20 CFR 411.505 - Selecting a Payment System	Unchanged
184457	c) 20 CFR 411.200(b) - SSA-1375 Form	Unchanged
184450	b) 20 CFR 411.535(a)(1)(iii) - VR Case Closures	Unchanged
184449	b) 20 CFR 411.145 & 411.325 - Requesting Ticket Unassignments Other-screens	Modified
184447	a) 20 CFR 411.166; 411.170(b) - Elecronic Data Sharing Other-screens	Unchanged

ICR Details

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