Information Collection

Work Incentives Planning and Assistance Program (WIPA)-- SSI & SSI Beneficiaries

IC 238019 under ICR 201908-0960-001 · OMB 0960-0629.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0629 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4565 Work Incentives Planning and Assistance Program (WIPA)-- SSI & SSI Beneficiaries	Form
SSA-4565 WIPA Intake Information SSA 4565 Mockup.pdf	Form

IC Title:

Work Incentives Planning and Assistance Program (WIPA)-- SSI & SSI Beneficiaries

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4565	WIPA Intake Information	SSA 4565 Mockup.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	12,500	12,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.