AATakeCharge Milestone Payment Request Form page 1 of 2

form updated 1/1/09

 

EIN number: 74-3171184 (Milestone-Outcome Payment Method)

 

Certification Payment Request

 

Beneficiary Name_________________________________________________

 

Beneficiary Social Security Number___________________________________

 

Employer’s Name___________________________________________________

 

Employer Address:___________________________________________________

 

To what address would like your 75% of the Ticket Payments (Work Support Payments) mailed?

 

Name:______________________________________________________

 

Address* _____________________________________________________

 

______________________________________________________

*Is this a NEW address? If so, please hand-write “NEW ADDRESS!” at the top of this form so we will update our records.

 

Phone: ______________________________________________________

 

Are you currently receiving benefit checks from Social Security? Yes___ No____

 

Please list the calendar month(s) for which you are claiming that your earned income exceeded the required levels. Prior to July 2008 those levels were $940/month if you have a general disability and $1,570/month if you are blind. For months July-December of 2008 the amount as $670/month. Starting in January of 2009 the target will be $700/month. Please list both month and year, for example July, 2008.

_____________ ____________ ____________

_____________ ____________ ____________

_____________ ____________ ____________

 

I certify that the information on this form is accurate to the best of my knowledge.

 

 

______________________________________________ _______________

Signature Date

(page 2 of 2)

 

Please note: Payment Evidence Required!

 

Please attach photocopies of your pay slips showing that you earned above the target level for the month(s) that you have listed on page one.

 

Copies of your pay stubs are the BEST form of evidence. If you do not have pay stubs or you are self employed please go to www.worksupportpayments.com and click on the Collect Payments link. There you will find instructions on alternative forms of earnings evidence that Social Security will accept for self-employed individuals.

 

Please understand, Social Security will not pay AATakeCharge for the months requested unless we can provide them with the required evidence of your earning!

 

 

 

 

Please mail this Payment Request Form to:

 

 

TakeCharge Processing

3703 Pan Am Expressway Ste 300

San Antonio, Texas 78219

 

 

 

Below line for AATakeCharge use only

_____________________________________________________________

By signing below, AATakeCharge agrees to repay any payments received from the Social Security Administration (or allow the amount to be deducted from future payments) if it is determined at a later date that AATakeCharge was not entitled to payment from the Social Security Administration for this Ticket claim.

 

__________________________________________________ __________________

AATakeCharge Representative Date