AATakeCharge Milestone Payment Request Form
DUNS 623626210 (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____
Are you currently, or did you receive (circle one): SSI SSDI SSI and SSDI
Please list the calendar month(s) for which you are claiming that your earned income exceeded the required levels. For the months of January 2010 to December 2010 the earnings amount is $720/month for Milestone Phase 1 and $1,000/month ($1,640/month for blind) for Milestone Phase2 and Outcome payments. Starting in January 2011 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.
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I certify that the information on this form is accurate to the best of my knowledge.
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Signature Date
* 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.
REQUIRED: Please indicate below how you spent the last work support payment you received from AATakeCharge. If this is your first Payment Request please indicate how you plan to spend your work support payment if it is approved. You may select more than one option:
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_____Transportation related |
_____Personal Care Assistance |
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_____Business/Work related clothing |
_____Additional training/ education |
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_____Job Coaching |
_____Self Employment expenses |
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_____Computer/cell phone related |
_____Child care or elder care |
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_____Health care |
_____ Other disability related supports |
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_____Other(please explain)________________________________________________________ |
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___ 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
14526 Jones Maltsberger, Ste 203
San Antonio, Texas 78247
Below line for AATakeCharge use only
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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.
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AATakeCharge Representative Date