Information Collection

WIPA Case Notes (SSA-4566)

IC 178887 under ICR 202203-0960-011 · 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⚠️ Notice: This information collection may be referencing outdated material.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 WIPA Case Notes (SSA-4566)	Form
SSA-4565 Wipa Case Notes SSA-4566 (revised).pdf	Form
SSA-4565 Help Line Work Incentives Planning and Assistance (WIPA) SSA-4565 (current).pdf	Form
SSA-4566 (current).pdf WIPA Case Notes (current)	IC Document
SSA-4565 (current).pdf WIPA Intake Information (current)	IC Document

IC Title:

WIPA Case Notes (SSA-4566)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 Case Notes	SSA-4566 (revised).pdf		No		Fillable Fileable Signable
Form	SSA-4565	Help Line Work Incentives Planning and Assistance (WIPA) Referral and WIPA Intake (SSA-4565)	SSA-4565 (current).pdf		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 360

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	320,400	312,900	7,500
Annual IC Time Burden (Hours)	10,680	8,180	2,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
WIPA Case Notes (current)	SSA-4566 (current).pdf	05/25/2022
WIPA Intake Information (current)	SSA-4565 (current).pdf	05/25/2022

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