Information Collection Request

Work Incentives Planning and Assistance (WIPA)

ICR 201908-0960-001 · OMB 0960-0629 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form SSA-4566 WIPA CASE NOTES Form Modified Available
Form SSA-4565 WIPA Beneficiary/Recipient Application Form Modified Available
Form SSA-4565 WIPA Intake Information Form New Available
Form SSA-4566 WIPA Case Notes Form New Available
Form SSA-4565 WIPA Intake Information Form New Available
Form SSA-4567 Help Line WIPA Referral Form Modified Available
Form SSA-4566 WIPA Case Notes Form Modified Available
Form SSA-4565 Wipa Intake Information Form Modified Repair queued
Supporting Statement 0629 (revised).docx Supporting Statement A Uploaded 2020-05-18 Available
Addendum - 0629.docx Supplementary Document Uploaded 2019-10-08 Available

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
05/31/2023 36 Months From Approved 05/31/2020
90,000 0 90,000
25,000 0 25,000
0 0 0





Reginfo record details
5
table that charts list of burden
IC Title Form No. Form Name
Work Incentives Planning and Assistance Program (WIPA) - Large Site (600 or more beneficiaries served) SSA-4566, SSA-4565 ,  
Work Incentives Planning and Assistance Program (WIPA)- (Small Site Under 150 Beneficiaries served) SSA-4565, SSA-4566 ,  
Work Incentives Planning and Assistance Program (WIPA)-- SSI & SSI Beneficiaries SSA-4565
Work Incentives Planning and Assistance Program (WIPA)--Help Line SSA-4567
Work Incentives Planning and Assistance Program (WIPA)--Medium Site (150-599 beneficiaries served) SSA-4565 , SSA-4566 ,  

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 90,000 90,000 0 0 0 0
Annual Time Burden (Hours) 25,000 25,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No