Information Collection

WIPA Case Notes (SSA-4566)

IC 178887 under ICR 202604-0960-007 · OMB 0960-0629.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4565 Wipa Case Notes WIPA Case Notes (SSA-4566)	Form
Form SSA-4565 Help Line Work Incentives Planning and Assistance (WIPA) Referral and WIPA Intake (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:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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				No		Fillable Fileable Signable
Form	SSA-4565				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	Previously Approved
Annual Number of Responses for this IC	320,400	320,400
Annual IC Time Burden (Hours)	10,680	10,680
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
WIPA Case Notes (current)		05/25/2022
WIPA Intake Information (current)		05/25/2022

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

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