Information Collection

Work Incentives Planning and Assistance Program (WIPA)- (Small Site Under 150 Beneficiaries served)

IC 9650 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⚠️ Notice: This information collection may be referencing outdated material.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)- (Small Site Under 150 Beneficiaries served)	Form
Form SSA-4565 WIPA Beneficiary/Recipient Application Work Incentives Planning and Assistance Program (WIPA)- (Small Site Under 150 Beneficiaries served)	Form
Form SSA-4566 WIPA CASE NOTES Work Incentives Planning and Assistance Program (WIPA)- (Small Site Under 150 Beneficiaries served)	Form
SSA-4565 WIPA Beneficiary/Recipient Application SSA 4565 Mockup.pdf	Form
SSA-4566 WIPA CASE NOTES SSA 4566 Mock-up.pdf	Form

IC Title:

Work Incentives Planning and Assistance Program (WIPA)- (Small Site Under 150 Beneficiaries served)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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 Beneficiary/Recipient Application	SSA 4565 Mockup.pdf		Yes	Yes	Fillable Fileable
Form	SSA-4566	WIPA CASE NOTES	SSA 4566 Mock-up.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: 4,800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-4,800	4,800
Annual IC Time Burden (Hours)	-1,600	1,600
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.