Employment Network (EN)
Certification of Services (COS) Statement
EN Name:
PID Number:
Ticketholder Name:
Ticketholder SSN:
Ticketholder Telephone:
Ticketholder Email:
Ticketholder Address:
T
icket Assignment Date:
Ticket Unassignment Date (if applicable):
Individual Work Plan (IWP) Addendum: Statement of Services
Please list all services that your EN provided (include date) to the Ticketholder to date. These
services are those agreed upon in the IWP to help the Ticketholder reach and sustain his or her
long-te
rm employment goals since both parties signed the IWP.
Social Security may verify the information above with the Ticketholder.
Did you attempt to contact the Ticketholder at least quarterly?
Yes
Dates of contact:
No
By signing below, the EN affirms having provided the services above to the Ticketholder.
EN Representative’s Name
EN Representative’s Signature
Date
