AAATakeCharge Outcome Payment Request Form

DUNS 017039558          (Outcome Only Payment Method)

 

Evidentiary 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____

 

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 Substantial Gainful Activity (SGA) level. (For 2010 SGA was $1000 per month if you have a general disability and $1,640 per month if you are blind. For 2011 SGA is $1,000 per month if you have a general disability and $1,640 per month if you are blind.) Please only list months for which you did NOT receive any Social Security benefit checks. You cannot receive a payment from AAATakeCharge and a benefit check from SSA for the same calendar month if you are collecting under the outcome only payment plan. Include both month and year, for example December, 2010 or January, 2011.

_____________ ____________ ____________

_____________ ____________ ____________

_____________ ____________ ____________

 

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

 

 

______________________________________________ _______________

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:

_____Transportation related	_____Personal Care Assistance
_____Business/Work related clothing	_____Additional training/ education
_____Job Coaching	_____Self Employment expenses
_____Computer/cell phone related	_____Child care or elder care
_____Health care	_____ Other disability related supports
_____Other(please explain)________________________________________________________

 

 

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

 

Val Pinter can be reached at 214-660-3640 or email her at aaatakecharge@gmail.com.

 

 

Below line for AAATakeCharge use only

_____________________________________________________________

By signing below, AAATakeCharge 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 AAATakeCharge was not entitled to payment from the Social Security Administration for this Ticket claim.

 

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AAATakeCharge Representative Date