Workforce Individual Work Plan

Workforce Individual Work Plan EN Name: DUNS #: IWP Date: Statement of Understanding: I choose to participate in the Ticket to Work Program with the Employment Network (EN) named above. My participation is VOLUNTARY. I understand that my EN will provide me with continuing employment support to find and keep a job, increase my earnings or run my own business. My goal is to increase my earnings to support myself and achieve self- sufficiency by establishing employment goals that are clear and measurable. I understand that I can change this plan with my EN as necessary to progress towards achievement of my employment goal. EN Address: Ticket Holder Name: Address:

City State Zip Code City State Zip Code EN Phone: Phone: EN Email: Mobile: Other Contact: SSN: Address: Email: Contact City State Zip Code Preference: Email Phone Mobile Relationship to Ticket holder: Educational Background No formal schooling Recent Work Activity: Elementary education (Grades 1-8) I am currently working, OR, had earnings within the last Secondary education, no High School 18 months (complete chart below) diploma (Grades 9-12)

I had no earnings in the last 18 months Special education certificate of (If earnings in the last 18 months, please list month and year completion / attendance you worked, use format mm/yy): High School diploma Post-secondary education, no degree Vocational Technical Certificate Associate degree Bachelor’s degree SSA disability benefits you receive: Master’s degree or higher SSI SSDI Method of IWP Completion: Concurrent Face to Face By Phone Rights and Remedies: I UNDERSTAND that I have the following rights under the Ticket to Work Program. As my EN 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. "Unassignment" letter should be submitted to the Program Manager with Ticket holder Name, SSN, Date, Signature and the name of the EN. 5. Informed me of the Timely Progress Review guidelines. 6. Will keep my personal information, including my Social Security number and information about my disability private and confidential. 7. Will use only qualified employees and/or providers to provide services to me. 8. Will provide me with a copy of this IWP and any changes in an accessible format. 9. May offer services outside of your Ticket services. Should I choose to purchase a service outside the Ticket services, a separate acknowledgment must be signed by both of us and attached to this IWP. 10. Explained your dispute 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. 11. Will ensure that if any arrangements are made for medical or related health services, those services will be provided under the supervision of persons licensed to prescribe or supervise the provision of those services in the state in which the services are performed. I declare under penalty of perjury that I have examined all the information on both pages 1 and 2 of this form and any accompanying statements or forms, and it is true and correct to the best of my knowledge. By signing below, (1) I acknowledge assignment of my ticket to this EN; (2) I agree to the terms of this IWP; (3) 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 Signature Date

Employment Network Representative Signature Date

Revised 12.1.2016 Workforce Individual Work Plan Workforce Individual Work Plan Services: Note: Goals must show progression to self-sufficiency Short-term Employment Goal (target goal: next 2 to 24 months.): Supports and Services to be Provided: 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 Expected Monthly Earnings: $840-$1169 $1170 or more * vocational goal. This includes any referrals my EN agreed to make to help me get services. Long-term Employment Goal (target goal: next 3-5 years): Career Counseling and guidance (required) Staff Providing Counseling: Duration of Career Counseling: (Hours) Expected Monthly Earnings: SGA or more? Yes Discussion Summary (describe goals, and whether reasonable and attainable): Projected number of work hours per week: Maximum number of miles willing to travel for job one way: 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 my unmet needs (at least quarterly)  I will inform SSA and my EN of my earnings monthly  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 (Spaces provided below can be used to describe detailed plans) can help me keep working Job search or placement services (required if not working) My EN and I have agreed to the other conditions described below (If there are no other conditions, please state that): None Continuing Employment Supports: My EN will provide long term follow-up supports that will help me sustain SGA level employment. Supports will include the following: Job accommodation assistance / planning

Social Security benefits / Work Incentives planning (check box below): Supports to be provided through WIOA (American Job Center) Providing internally (certified advisor on staff), OR Referring to WIPA: Financial Capability Planning / list services and/or referrals: WIPA Contact Name: WIPA Contact Phone: Training (specify type/source): Resume Development Transportation planning / service referral Referral to other related services or support providers (please list): * Figures in this Workforce IWP indicate 2017 values as follows: Trial Work Level = $840/month Non-blind SGA level = $1,170/month Blind SGA level = $1,950/month

Developed by NDI Consulting, Inc. This project has been funded, either wholly or in part, with Federal funds from the Department of Labor under Contract No.: Revised 12.1.2016 DOLJ131A22067. The contents of this publication do not necessarily reflect the views or policies of the Department of Labor, nor does mention of trade names, commercial products, or organizations imply endorsement of same by the U.S. Government.