Work Incentives Planning and Assistance Community Work I

OMB No. 0960-0629

Work Incentives Planning and Assistance

Community Work Incentives Coordinator (CWIC) Application (formerly Benefit Specialist Form)

1. Site ID: __ __ __ __ __ __

2. Identifying information:

Last Name: ________________________ First Name: _________________ MI: ___

Title: ____________________________________

3. Date CWIC began providing services (MM/DD/YY): __ __/__ __/__ __

4. Contact Information:

Email: _______________________________________

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

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

Street Address (it is presumed that the city and state are the same as the Site):

________________________________________________________________________

Zip Code: __ __ __ __ __ - __ __ __ __

CWIC ID: This identifier is assigned when the benefit specialist information is entered, and is required to review or enter 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.