Ticket Unassignment Form (revised)

Finding the right service provider is an important step on your journey toward financial
independence! If you have decided to end your relationship with your current provider,
you have the right to unassign your Ticket and take it to another provider.
If you have questions about your unassignment or about Ticket to Work, please call the
Ticket to Work Help Line at 1-866-968-7842 or 1-866-833-2967 (TTY) Monday through
Friday, 8:00 a.m. to 8:00 p.m. ET.
To unassign your Ticket, please provide the following information:
Name:
Phone Number:
Social Security Number:
Employment Network (EN) Name:
Please identify the reason(s) you are unassigning your Ticket from this EN.
Check all that apply.
Not satisfied with services
Cannot contact/ non-responsive
Found another provider
No longer interested in participating in Ticket to Work
Health issues
Other
I,

request that my Ticket be unassigned from this EN.

Signature: ___________________________________________________ Date: ________________________
Mail this completed form to:
Ticket Program Manager (TPM)
ATTN: Ticket Unassignment
P.O. Box 1433
Alexandria, VA 22313
Or fax it to:
703-893-4020
ATTN: Ticket Unassignment