Information Collection

Work Incentives Planning and Assistance Program (WIPA)-- SSI & SSI Beneficiaries (SSA-4565)

IC 238019 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⚠️ Notice: This information collection may be referencing outdated material.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 Work Incentives Planning and Assistance Program (WIPA)-- SSI & SSI Beneficiaries (SSA-4565)	Form
SSA-4565 WIPA Intake Information SSA-4565 (revised).pdf	Form
SSA-4566 WIPA CASE NOTES SSA-4566 (revised).pdf	Form
SSA-4565 (current).pdf Work Incentives Planning and Assistance Program (WIPA)-- SSI & SSI Beneficiaries (SSA-4565)	IC Document
SSA-4566 (current).pdf WIPA CASE NOTES (SSA-4566)	IC Document

IC Title:

Work Incentives Planning and Assistance Program (WIPA)-- SSI & SSI Beneficiaries (SSA-4565)

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 Intake Information	SSA-4565 (revised).pdf		No		Paper Only
Form	SSA-4566	WIPA CASE NOTES	SSA-4566 (revised).pdf		Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 32,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	32,000	2,000	30,000
Annual IC Time Burden (Hours)	13,333	833	12,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Work Incentives Planning and Assistance Program (WIPA)-- SSI & SSI Beneficiaries (SSA-4565)	SSA-4565 (current).pdf	05/25/2022
WIPA CASE NOTES (SSA-4566)	SSA-4566 (current).pdf	05/25/2022

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