Form Date:
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.
EN Name:
Address:
Address:
WorkNet Pinellas
2312 Gulf to Bay Blvd
Clearwater,
City
Phone: 727
City
608
FL
State
2552
Email: scaum@worknetpinellas.org
Other Contact:
State
Relationship to Ticket holder:
Recent Work Activity:
33765
Zip Code
Zip Code
I am currently working, OR, had earnings within the last
18 months (complete chart below)
I had no earnings in the last 18 months
(If you had earnings in the last 18 months, prior to the month of
Ticket assignment, please list any month/year you worked):
Ticket holder:
Address:
City
Phone:
Email:
SSN:
FL
State Zip Code
Email:
Phone:
Area Code
Educational Background
No formal schooling
Elementary education (Grades 1-8)
Secondary education, no High School diploma
(Grades 9-12)
Special education certificate of completion / attendance
High School diploma
Post-secondary education, no degree
Vocational Technical Certificate
Associate degree
Bachelor’s degree
Master’s degree or higher
I have read and understand the following:
1. The Employment Network, hereafter designated as EN,WorkNet will not request or receive any compensation directly from me for the costs of services and supports provided to me.
2. The EN reserves the right to amend the IWP or terminate the relationship under the following conditions:
● Change in Vocational goal ● Non-compliance with outlined steps in IWP ● Non-active participation
3. The Ticket to Work and Self-Sufficiency Program has been established to provide Social Security beneficiaries more choices for receiving employment related services. Should I be dissatisfied with the services being provided by the
EN, I may retrieve the Ticket at any time.
4. For disputes between myself and the EN, I will be referred to WorkNet Human Resource Dept. for grievance procedures. If we are unable to resolve a dispute, I also understand I can contact the State Protection and Advocacy
Agency at (850)488-9071 which can provide free advocacy services to me.
5. The EN will keep all information of a personal nature provided by me, including Social Security number and information about my disability, strictly confidential.
6. The EN and I may amend the IWP, however, the EN and I must agree upon all changes, and changes must be submitted and approved by the Operations Support Manager (Maximus).
7. I have the right to a copy of the IWP in a format I have chosen at any time.
8. I have received a statement of terms and conditions related to the provision of services and supports to be provided by my EN.
9. Only qualified employees and/or providers will be used to furnish services to me as outlined in IWP.
10. EN has informed me of the annual progress reviews and the Timely Progress Review (TPR) guidelines, and has these guidelines in written format for Ticket holders.
11. I consent to allow EN to sign for me, any Certification of Services, which may be required by the EN to receive certain payments, and which states that agreed upon services have been provided to me.
12. By signing this IWP, I understand that I am responsible for reporting wage data to this EN, the EN may report my wage data to the Social Security Administration, and if necessary, the EN has the right to contact my current or future employers to verify work activity and earnings amounts.
I declare under penalty of perjury that I have examined all the information on the form and any accompanying statements or forms, and it is true and correct to the best of my knowledge.
Beneficiary Signature
Employment Network Representative Signature
WorkNet , DUNS # 044572316
Date
Date
Revised May 17, 2013
WorkNet Pinellas is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone numbers listed may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711.

Short-term Vocational Goal (next 3 to 12 mos.):
Long-term Vocational Goal (next 3-5 years):
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 (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 other conditions have been agreed upon at this time.
Projected monthly earnings in the next 3-12 months : $750.00
Projected monthly earnings in the next 3-5 years:
Projected number of hours: /week
Maximum distance beneficiary is willing to travel to new job: ______
Expected type of job (EEOC classification):
Executive / Managerial
Professional
Sales
Technical / Paraprofessional
Skilled craft
Secretarial / Office / Clerical
Service worker
Operative
Laborer
Miles
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 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)
Interest Inventory, O-net, labor market and occupational information
Job search or placement services (required if not working)
Resume, job leads, referrals, job development and support as needed
Job coaching / training
Job accommodation assistance / planning
Social Security benefits/ Work Incentives planning information/referral
Resume Development
Transportation planning assistance
Referral to other services or support providers
Training (specify source)
Continuing Employment Supports (check one box below):
$1050.00
My EN will provide all agreed services for initial and ongoing follow-up
supports (quarterly follow-up required)
My EN will provide agreed upon services for initial supports to assist me
in securing employment (Phase 1), after which, I will need to find
another EN to assist me with long term follow-up supports.
My EN will partner with the following agency for agreed upon services
for both the initial AND long term follow-up supports (please list below):
Note: Long term follow-up supports imply that an EN will provide supports that will help Ticket holders sustain SGA level employment
Other services (please note who they will be provided by below):
FOR EN’S COMPLETION
Record of Career Counseling Provided During IWP Development
Date of Counseling:
Date of Counseling:
Duration of Counseling Session:
Duration of Counseling Session:
Name of Counselor: Susannah Caum
Revised May 17, 2013
WorkNet Pinellas is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone numbers listed may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711.