TakeCharge Individualized Work Plan and Contract        (updated 10/30/2008)                                                                                                                                      

 

 

1.     Please select one of the two TakeCharge Employment Networks below by placing an X  in front of your choice.     Please read ÒTips for selecting a TakeCharge ENÓ on page 3 before selecting  A or B below.    

 

_______   A)    AATakeCharge Milestone EIN  743171184           (milestone-outcome method)

 

_______   B)    AAATakeCharge    EIN 943368908          (outcome-only method)     

 

   2.     Beneficiary Name (Last, First MI)

 

___________________________________________________________________

 

 

3.  Social Security Number________________________________________

 

4.                     Telephone                                  (                )    _________________________

5.                     E-mail address (if you have one) ___________________________________

 

6. Please print your address clearly!   

   Street:   _________________________________________________________

  City, State, Zip Code:   __________________________________________________

 

7.  Vocational Goal: ___________________________________________________________

(You MUST list an occupation such as teacher, sales clerk, web master, stock broker or truck driver.  If you are uncertain as to what kind of job offer you are likely to accept, write in your best guess.  No one will hold you to it.)

  

8.  How much is beneficiary currently earning from their work each month? (check one)

 $0 - $670______                $671 - $940______            more than $940 per month______

 

9.  I received a recorded voice message on my telephone telling me that I could receive work support payments under the Ticket to Work program      ____Yes      ____No

 

10.  How did you FIRST learn about TakeCharge?   State Vocational Rehab Agency____

Recorded message delivered to phone______   Found on list of all Employment Networks providing services in my area______    Other (please describe)_________________________

 

 

 

 

 

Supports/Services provided over entire period of client participation                                                             

● Generic job search advice and disability information found on www.worksupportpayments.com                        

● 75% of any Ticket payments received on behalf of the client.                                      

 

Consumer Rights & Remedies

 

As a consumer of either TakeCharge EN you have the following rights: 

 

  1. Your EN may not request or accept any compensation from you for the cost of services and supports we provide to you. 
  2. This IWP may be amended if both parties agree.
  3. Your EN may end our relationship  with you at any time if we are no longer able or willing to provide services as planned.
  4. You may retrieve your Ticket at any time if you are dissatisfied with the services and supports being provided to you.
  5. If you and your EN are unable to resolve any disputes about the services and supports being provided, the internal dispute resolution process will be available to you.  You may also contact the State Protection and Advocacy Program for assistance.
  6. Your EN has informed you, the beneficiary,  of the annual progress reviews and the Timely Progress Review guidelines which are posted on our website.
  7. Your personal information including your Social Security number and information about your disability will be kept private and confidential.
  8. Only qualified employees and/or providers will be used to furnish services.
  9. No medical or related health services will be provided by either TakeCharge EN.
  10. A copy of this IWP will be provided to you in an accessible format if requested.

 

TERMS and CONDITIONS related to the provision of services:  I agree that work support payments provided to me will be spent on goods and/or services that will help me remain in the workforce or advance in my career. 

 

Note:  if you selected AATakeCharge Milestone, LLC in question #1 you must complete the Earnings History chart on page 4 and mail it with this IWP/contract. 

 

 

__________________________________               ______________________________

BeneficiaryÕs Signature                                         EN RepresentativeÕs Signature

 

__________________________________               ______________________________

Date                                                                              Date

 

 

 

 

 

Please mail form to:                         TakeCharge Processing 

                                                            3703 Pan Am Expressway Ste 300

                                                            San Antonio, Texas   78219

 

 

 

 

              Tips for Selecting a TakeCharge EN      (updated 9/14/2008)

 

 

SSDI or dual SSDI/SSI beneficiaries:  Select AATakeCharge Milestone LLC (milestone-outcome method)  if:

 

●  You expect your earnings to be more than $670 per month, but not enough to exceed Substantial Gainful Activity (SGA) which is currently $940 per month if you have a general disability, and $1,570 if you are blind.

 

●  You do expect to earn a little more than SGA ($940/month for general, $1,570/month for blind), but plan on remaining on benefits indefinitely by using Impairment Related Work Expenses or Work Subsidies.

 

●  You do expect your benefits to be terminated due to your earnings once your trial work months over, but you still have at least 2 more trial work months to go and you want your payments from TakeCharge to start as soon as possible.

 

All others on SSDI or both SSDI/SSI should select AAATakeCharge which uses the outcome-only method of payment.  Outcome-only payments cannot start until your SSA benefit checks stop.  And outcome-only payments will stop if your earnings dip below $940 per month.  However, outcome-only payments will yield about 10% more than milestone-outcome payments over the course of three years.

 

 

SSI Recipient:  Select AATakeCharge Milestone, LLC (milestone-outcome method of payment) if:

 

●  You expect to earn over $670 per month but not enough to reduce your federal SSI check to zero.

 

All others receiving SSI checks only should select AAATakeCharge.  You will receive about 10% more under the outcome –only payment method over the course of 5 years.

 

 

 

Still Not Sure?

 

 (See Work Support Payment chart for more payment details).

 

 

 

 

 

 

 

Name __________________________                                                                                                                               

 

 

EARNINGS HISTORY - required only for those signing up for AATakeCharge Milestone

 

Social Security wants to know if your earnings have exceeded $670.00/month in any of the 18 months prior to your Ticket assignment.  If you are assigning your Ticket to AAATakeCharge you do NOT need to complete this page.

 

Have you earned more than $670 per month in the past 18 months?      _____yes           _____no

 

If no, just send this form in with your contract.

 

If yes, please complete the chart below and mail this form in with your contract.

Write the current month in the LAST box, then work BACKWARD listing each preceding month (see sample below). Enter an X below each month in which you had earnings of more than $670.00 in that month. If you are uncertain about a given month, make your best guess.

 

 

 

Example:

 

Month/Year

 

April 07

May 07

June 07

July 07

August 07

September 07

October 07

November 07

December 07

January 08

February 08

March 08

April 08

May 08

June 08

July 08

August 08

September 08

 

Earned > $670?

 

 

 

 

 

 

 

 

 

X

 

 

X

X

 

 

 

 

 

 

 

 

 

 

Current month here ↓

Month/Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Earned > $670?