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.

Documents and Forms

Document Name Document Type
Form SSA-4565 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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.