Work Incentives Planning and Assistance formerly BPAO

OMB No. 0960-0629

Work Incentives Planning and Assistance formerly BPAO

Project Site Application

1. Project Name (SSA grantee name): ________________________________

2. Project Site (provider agency name): ________________________________

3. Primary contact person for data:

Last Name: ________________________ First Name: _________________

Email: _______________________________________

4. Date Site began operation (MM/DD/YY): __ __ /__ __ / __ __

5. Site Contact Information:

Full Address:

City: _______________________State: ___ ___ Zip Code: __ __ __ __ __ - __ __ __ __

Telephone: (__ __ __) __ __ __ - __ __ __ __

Fax: (__ __ __) __ __ __ - __ __ __ __

Site ID: This identifier is assigned when the site Information is entered, and is required to review or enter either benefit specialist information or beneficiary/recipient information.

Write it down here when the computer gives it to you: ___ ___ ___ ___ ___ ___

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995.  You do not need to answer these questions unless we display a valid Office of Management and Budget control number.  We estimate that it will take about 2 minutes to read the instructions, gather the facts, and answer the questions.  You may send comments on our time estimate above to:  SSA, 6401 Security Blvd, Baltimore, MD  21235-6401.  Send only comments relating to our time estimate to this address, not the completed form.