Ticket to Work Interest Form

    Are you between the ages of 18-64?
    YesNo

    Are you currently receiving SSI?
    YesNo

    Are you currently receiving SSDI?
    YesNo

    Are you a ticket holder?
    YesNo

    Are you interested in returning to work with the ultimate goal of getting off Social Security completely and becoming self-sufficient?
    YesNo

    Have you met with a Certified Work Incentives Coordinator (CWIC) to review how work will impact benefits?
    YesNo

    Have you met with any other EN or DOR?
    YesNo