Evidentiary Payment Request

Beneficiary Name______________________________________________________

Beneficiary Social Security Number_______________________________________

Employer’s Name______________________________________________________

Employer’s Address____________________________________________________

To what address would you 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 Substantial Gainful Activity (SGA) level. (For 2009 SGA is $980 per month if you have a general disability and $1,640 per month if you are blind. For 2010 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, 2009 or January, 2010.

_____________ ____________ ____________

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 SGA for the month(s) that you have listed on page one. Copies of your pay stubs are the BEST form of evidence. The pay statements must show the pay period dates, pay dates, gross earnings and FICA tax 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. Please understand Social Security will not pay AAATakeCharge for the months requested unless we can provide them with the required evidence of your earnings!

Mail this Payment Request Form to:

AAATakeCharge Processing

12332 I-H10 West

San Antonio, TX 78230

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.

__________________________________________________ __________________

AAATakeCharge Representative Date

Contact Information for the Employment Network Representative Submitting this Request

Print Name: ___________________________________________________________

Phone Number: _________________________________ FAX: _____________________________

Email: ________________________________________________________

* 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.