Information Collection

Work Incentives Planning and Assistance Program (WIPA)-- SSA-4565 SSI & SDSI Beneficiaries (Fields 1-20)

IC 238019 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 Intake Information Work Incentives Planning and Assistance Program (WIPA)-- SSA-4565 SSI & SDSI Beneficiaries (Fields 1-20)	Form
Form SSA-4566 WIPA CASE NOTES Work Incentives Planning and Assistance Program (WIPA)-- SSA-4565 SSI & SDSI Beneficiaries (Fields 1-20)	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:

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		Paper Only
Form	SSA-4566				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: 15,810

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15,810	-16,190	32,000
Annual IC Time Burden (Hours)	3,953	-9,380	13,333
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)		05/25/2022
WIPA CASE NOTES (SSA-4566)		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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