Information Collection

SSA-4565 (Fields 21-63 – SSI & SSDI Beneficiaries (by phone)

IC 282588 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 Help Line Work Incentives Planning and Assistance (WIPA) Referral and WIPA Intake SSA-4565 (Fields 21-63 – SSI & SSDI Beneficiaries (by phone)	Form and Instruction
Attachment C - Comprehensive List of SSA-4565 Data Elements.docx	Other-Comprehensive List of SSA-4565
SSA-4565 Help Line Work Incentives Planning and Assistance (WIPA) SSA-4565 (revised).pdf	Form and Instruction
SSA-4565 (current).pdf Help Line Work Incentives Planning and Assistance (WIPA) Referral and WIPA Intake	IC Document

IC Title:

SSA-4565 (Fields 21-63 â SSI & SSDI Beneficiaries (by phone)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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 and Instruction	SSA-4565				Yes	Yes	Fillable Fileable Signable
Other-Comprehensive List of SSA-4565 Data Elements					No		Paper Only

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: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Help Line Work Incentives Planning and Assistance (WIPA) Referral and WIPA Intake		09/25/2026

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

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