AATakeCharge Milestone Payment Request Form page 1 of 2
form updated 5-28-10
EIN number: 74-3171184 (Milestone-Outcome Payment Method)
Evidentiary Payment Request
Beneficiary Name_________________________________________________
Beneficiary Social Security Number___________________________________
EmployerÕs 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 ÒNEW ADDRESS!Ó 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. For the months of January 2009 to December 2009 the earnings amount is $700/month for Milestone Phase 1 and $980/month ($1,640/month for blind) for Milestone Phase2 and Outcome payments. Starting in January 2010 the earnings amount is $720/month for Milestone Phase 1 and $1000/month ($1,640/month for blind) for Phase 2/Milestones and Outcome payments. Please list both month and year, for example January 2010.
_____________ ____________ ____________
_____________ ____________ ____________
_____________ ____________ ____________
I certify that the information on this form is accurate to the best of my knowledge.
______________________________________________ _______________
Signature Date
(page 2 of 2)
___ A. The beneficiary achieved TWL level earnings during the calendar claim month.
___ B. The beneficiary achieved less than TWL, but he/she will achieve TWL earnings within the next two months.
___ C. The beneficiary achieved less than TWL and is not expected to achieve TWL earnings within the next two months.
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. Pay statements must show the pay period dates, pay date, gross earnings and FICA taxes withheld. 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
12332 W IH 10
San Antonio, Texas 78230
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
Contact Information for the Employment Network Representative Submitting this Request
Print Name: ___________________________________________________________
Phone Number: ___210-637-5610__________________ FAX: ____210-494-1075_________
Email: ____takecharge75@gmail.com______________________________
* Please note that occasionally Social Security discovers a payment has been made in error. If this happens your case will be placed in overpayment status until Social Security recoups the funds. More details will be provided to you if your case goes into an overpayment status.