Information Collection

WIPA STAR SYSTEM: WIPA Case Notes (SSA-4566) (WIPA Staff)

IC 178887 under ICR 202609-0960-011 · OMB 0960-0629.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4565 Wipa Case Notes WIPA STAR SYSTEM: WIPA Case Notes (SSA-4566) (WIPA Staff)	Form
Form SSA-4565 Help Line Work Incentives Planning and Assistance (WIPA) Referral and WIPA Intake (SSA-4565) WIPA STAR SYSTEM: WIPA Case Notes (SSA-4566) (WIPA Staff)	Form
SSA-4565 Wipa Case Notes SSA-4566 (revised).pdf	Form
SSA-4565 Help Line Work Incentives Planning and Assistance (WIPA) SSA-4565 (revised).pdf	Form
SSA-4565 (current).pdf WIPA Intake Information (current)	IC Document

IC Title:

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				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: 1

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	1	-320,399	320,400
Annual IC Time Burden (Hours)	0	-10,680	10,680
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
WIPA Intake Information (current)		09/25/2026

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].