Ticket to Work Individual Work Plan (IWP)

Ticket to Work Individual Work Plan (IWP)

Statement of Understanding: I choose to participate in the Ticket to Work Program with the employment network (EN) named below. I understand that my EN will provide me with employment support to find and keep a job, increase my earnings or run my own business. If possible, I plan to increase my earnings to support myself. I understand that I can change this plan with my EN from time to time to meet my current needs.

*WHEN COMPLETED, PLEASE SEND THIS BACK TO US VIA MAIL, FAX, OR SCANNED INTO AN EMAIL. FOR FASTEST PROCESSING TIMES PLEASE FAX OR EMAIL.

Employment Network Name: A Center for Healing, Change, and Career Advancement / DUNS: 26-1753121/ 829166490
Address: 3090 S Jamaica Ct Suite 101 Aurora CO / Telephone: 1-800-592-9571
Fax: 1-866-299-7391
Email:
My Name: / SSN:
Address: / Telephone:
Email:

• Alternate Contact’s Name:

/ Telephone:
Address: / Email:

* Self Starter Program- you will receive 20% of your ticket payments*

Before you submit this form, please double check that ALL sections of the application are filled out. Incomplete applications will not be accepted.

1. My Vocational Goal and Expected Monthly Earnings

Short Term Vocational Goal (in the next 3 to 12 mos.):

______

Expected Monthly Earnings (in the next 3 to 12 mos.):

______

Long Term Vocational Goal (in the next 3-5 years):

______

Expected Monthly Earnings (in the next 3-5 years):

______

2. The Supports and Services the EN Agreed to Provide to Help Me Reach My Vocational Goal.

My EN and I have agreed upon the supports/services checked or written below. Below we also explain the steps the two of us agreed to take to help me reach my vocational goal. This includes any referrals my EN agreed to make to help me get services.

Career counseling and guidance (at a minimum, required during IWP development)

Note:On the last page, EN must certify to providing career counseling.

• With the self starter program clients only receive LIMITED supportive services. These services include a resume if needed, and 2 (1) hour-long consultations where we give you a plethora of resources and assistance on where to look for work. Once you start work we will connect with you quarterly to see how your job is going. ______
• ______
• ______
• ______

Job search or placement services (required, if not working)

• We provide services including job search assistance, internet search assistance, website resources, interviewing practice, follow up protocols, etc.______
• ______
• ______

Continuing employment supports (at a minimum, quarterly contact by EN to assess needs)

• ______
• ______

Other (please explain below)

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• ______
• ______

3. My Recent Work History (Check all that apply)

 I am currently working.

 I had no earnings in the last 18 months.

 I had some earnings in the last 18 months.

 None of my earnings were in the last 6 months.

 Some of my earnings were in the last 6 months.

(If you had earnings in the last 6 to 18 months, please describe those earnings in the following chart. List your latest employer first.)

Employer / Start Date / End Date / Wage Per Hour / Hours Worked Per Week

4.Conditions Related to the Success of my IWP

• I will inform my EN of changes in my contact information.
• My EN will contact me as needed to share information and determine any unmet needs. (at least quarterly).
• I will inform my EN of my earnings.
• While I am working, my EN will offer and provide me with ongoing employment support to help me keep working or refer me to others who can help me keep working.

My EN and I have agreed to the other conditions described below. (If there are no other conditions, please state that:)

NO CONDITIONS______

RIGHTS & REMEDIES

I understand that I have the following rights under the Ticket to Work Program. As my EN, A Center for Healing and Change, you:

1) May not request or accept any compensation from me for the costs of services and supports provided to me as an EN.

2) May change this IWP, as long as we both agree. Any change to this IWP must be made in writing.

3) Will provide or help me to obtain ongoing employment support, as necessary, designed to help me keep my job.

4) May unassign my Ticket at any time if either of us are not satisfied for any reason.

5) Explained its internal resolution process. If we are unable to resolve a dispute, another process is available to me through the Ticket Call Center at 1-866-968-7842.

6) Provided me with the phone number of the State Protection and Advocacy Program where I can receive free services. The phone number is ______.

7) Informed me of the annual progress reviews and the Timely Progress Review guidelines.

8) Will keep my personal information, including my Social Security number and information about my disability, private and confidential.

9) Will use only qualified employees and/or providers to provide services to me.

10) Will provide me with a copy of this IWP and any changes in an accessible format.

I declare under penalty of perjury that I have examined all the information on the form and any accompanyingstatements or forms, and it is true and correct to the best of my knowledge.

By signing below, I agree to the terms of this IWP and give permission for the EN named in this IWP to contact employers on my behalf to verify or obtain evidence of work or earnings.

Beneficiary's Signature: / EN Representative's Signature:
Date: / Date:

______FOR EN’S COMPLETION

Record of Career Counseling Provided During IWP Development
______
(Date of Counseling) (Duration of Counseling Session)
______
(Date of Counseling) (Duration of Counseling Session)
______
(Name of Counselor)

EN Payment Request Form

This form may be used to request Evidentiary Payment Requests

(EPRs) or Certification Payment Requests (CPRs)

To ensure prompt and accurate payment to your Employment Network, please complete the following form and attach any acceptable earnings information required.

*PLEASE JUST FILL SECTION II AND AND ONCE YOU START WORK YOU WILL FAX IN COPIES OF YOUR PAYSTUBS TO 1-866-299-7391. IF YOU HAVE ALREADY SUBMITTED THE CHECKSTUBS FOR THE PREVIOUS MONTHS YOU DO NOT NEED TO RESUBMIT THE SAME CHECK STUBS OVER AGAIN.

I.Employment Network Information
1.EN Organization Name: A Center for Healing, Change, and Career Advancement____
2.DUNS Number ______829166490______
3.Is the financial institution and bank account information provided to the Ticket to Work Operations Support Manager on the Automated Clearinghouse Payment Enrollment Form (ACH Form) current?
Yes _X__ No ___ (if No, please contact MAXIMUS @ 1-866-949-3687 before submitting this request)
Incorrect or outdated information may delay or prevent payment issuance to your Employment Network.
II.Ticket-holder Information
4.Ticket-holder’s Name: ______
5. Ticket Number/Social Security Number: ______
6.Name of Ticket-holder’s Employer: ______
7.Employer’s Address (if available): ______
8.Payment Method for this Ticket Assignment
A. Outcome Payment Method ______B. Milestone-Outcome Payment Method___X___
III.Phase 1 - Milestone 1 Earnings Information (Complete only if requesting Phase 1 Milestone 1)
Please choose one of the following options by placing an “X” next to your selection:
_x__ A. The beneficiary achieved TWL earnings during the calendar claim month.
(TWL = $720-2010, $700-2009, $670-2008)
___ B. The beneficiary achieved less than TWL, but expects to achieve TWL earnings within the next 2 months.
___ C. The beneficiary achieved less than TWL earnings and is not expected to achieve TWL earnings within the next 2 months.
IV.Payment Request Details
9.Payment Request Type
____X__A. Evidentiary Payment Request – (Complete Section V)
______B. Certification Payment Request – (Complete Sections VI and VII)
10.Claim month(s) on the paystub and year(s) for this payment request:
______
______
V.Evidentiary Earnings Information
11.Type of earnings documentation submitted: (these items must be included with this form)
_x__ Pay slips
___ Employer prepared and signed employee earnings statement
___ Records from Third Party Source containing monthly wage information
____The Work Number ____Other
VI.Certification Payment Request Details
12.Type of Certification Information (Choose one):
____ Recent contact with beneficiary/employer (please circle “beneficiary” or “employer”)
____ Attached Earnings Inquiry Request (EIR) response received from MAXIMUS
____ Attached information containing data from the National Directory of New Hires (NDNH)
____ Attached Self Employment Income (SEI) Form (if beneficiary is self-employed)
13.Recent Contact Details (complete only if you selected “recent contact” on item 12):
Type of contact (phone call, email, etc): ______
Date of contact: ______
Description of information you learned from contact regarding level of earnings:
______
______
______
VII.Repayment Agreement (signature required):
By signing below, you as the EN agree to repay any payments received (or allow the amount to be deducted from future payments) if it is determined at a later date that you were not entitled to payment.
Signature: Kelly Johnson Date: on file .
VIII.Contact Information for the Employment Network Representative Submitting this Request
Print Name: ______Kelly Johnson______
Phone Number: ____720-204-8747______FAX: _____1-866-299-7391
Email:______

AUTHORIZATION TO RELEASE/REQUEST PAYMENT INFORMATION

Ticket to Work Client Name:______

Kelly Johnson may request information from employer verifying payment information and check stubs:

Checkmark information to be released:

_____ payment history/Work Stubs

and the information above is accurate to the best of my knowledge. A photocopy or facsimile of this release is as effective as the original. I hereby release the above parties from any liability that may result from furnishing this information.

Ticket to Work Client Signature:______

Date:_____

Ticket to Work Representative Signature:______

Date:______

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