#### 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.

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| ## I. Employment Network Information                                  |
|                                                                       |
| 1\. EN Organization Name:                                             |
| \_\_\_\_\_\_\_\_\_\_\                                                 |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| 2\. EIN Number (Tax ID Number):                                       |
| \_\_\_\_\                                                             |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| 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 \_\_\_ No \_\_\_ (if No, please contact MAXIMUS @ 1-866-968-7842  |
| before submitting this request)                                       |
|                                                                       |
| Incorrect or outdated information may delay or prevent payment        |
| issuance to your Employment Network.                                  |
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+-----------------------------------------------------------------------+
| #                                                                     |
|                                                                       |
| # 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 Paymen                                              |
| t Method \_\_\_\_\_\_ B. Milestone-Outcome Payment Method\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| #####                                                                 |
|                                                                       |
| ##### III. Payment Request Details                                    |
|                                                                       |
| 9\. **Payment Request Type**                                          |
|                                                                       |
| **\_\_\_\_\_\_\_ A. Evidentiary Payment Request -- (*[Complete        |
| Section IV)]{.underline}***                                           |
|                                                                       |
| **\_\_\_\_\_\_\_ B. Certification Payment Request -- (*[Complete      |
| Sections V and VI)]{.underline}***                                    |
|                                                                       |
| 10\. Claim month(s) and year(s) for this payment request:             |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+

##### 

+-----------------------------------------------------------------------+
| #####                                                                 |
|                                                                       |
| ##### IV. Evidentiary Earnings Information                            |
|                                                                       |
| ##### 11. Type of earnings d                                          |
| ocumentation submitted: (these items must be included with this form) |
|                                                                       |
| \_\_\_ Pay slips                                                      |
|                                                                       |
| \_\_\_ Employer prepared and signed employee earnings statement       |
|                                                                       |
| \_\_\_ Records from Third Party Source containing monthly wage        |
| information                                                           |
|                                                                       |
| > \_\_\_\_The Work Number \_\_\_\_Other                               |
|                                                                       |
| #####                                                                 |
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##### 

+-----------------------------------------------------------------------+
| #####                                                                 |
|                                                                       |
| ##### V. 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:                                                          |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| **VI. 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 Date                                                      |
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##### 

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| VII\. Contact Information for the Employment Network Representative   |
| Submitting this Request                                               |
|                                                                       |
| > **Print Name:                                                       |
| > \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                       |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |
|                                                                       |
| ### Phone Number: \_\_\_\_\_\_\_\_\_\_\                               |
| _\_\_\_\_\_\_\_\_\_ FAX: ­­\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| **Email:                                                              |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                         |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |
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