Work Incentives Planning and Assistance Program (WIPA)-- SSI & SSI Beneficiaries (SSA-4565)

Form SSA-4565 (06-2020)
Social Security Administration

Page 1 of 9
OMB No. 0960-0629

WIPA Intake Information
1. Date:

2. CWIC:

3. Referral Source:
Help Line

State VR Agency

Other (specify)

Beneficiary Demographics
4. Name:

5. Social Security Number:

6. Medicare Claim Number
(if different from SSN):

7. Medicaid Number
(if applicable):

8. Date of Birth:

9. Age:

10. If over age 18 and receiving SSI, has Social Security conducted the Age 18 redetermination?
Yes

No

11a. Was the beneficiary disabled prior to age 26?

Yes

No

11b. If "Yes," does the beneficiary have an Achieving a Better Life Experience (ABLE) account?

Yes

12. List the primary disability:
13. Statutorily blind?

Yes

No

14. When did the disability begin?
15. Is the beneficiary a U.S. Military Veteran?
16. Marital Status:

Single

Married

Yes
Divorced

No
Separated

Widow(er)

17. List other people in the household
Name

Age

Receiving Benefits?

No

Form SSA-4565 (06-2020)

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18. If any household member (spouse or children) receives any type of means-tested benefits describe:

19. For SSI and Medicaid recipients only, describe all income or in-kind support received including source
and amount of income:

20. Does the beneficiary have a My Social Security account?

Yes

No

Recommended

21. Primary contact information:
Beneficiary

Representative Payee

Guardian

Other (specify)

22. Address (include city, state, and ZIP):

a. Home:
23. Phone b. Cell:

c. Work:

d. TTY/Videophone Number/IP address:
24. Email address:
25. Best time to reach:
26. Preferred manner of contact:
Telephone

Email

In-Person

Skype or Other Video Conferencing

Other (specify)

Via an Interpreter

27. Benefits Summary and Analysis (BS&A) delivery:
Telephone

Email

Via an Interpreter

In-Person
Other (specify)

28. Describe language or accommodation needs:

Skype or Other Video Conferencing

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29. Alternate contact information:
Beneficiary

Representative Payee

Guardian

Other (specify)

30. Address (include city, state, and ZIP):

a. Home:
31. Phone b. Cell:

c. Work:

d. TTY/Videophone Number/IP address:
32. Email address:
33. Best time to reach:
34. Preferred manner of contact:
Telephone

Email

Via an Interpreter

In-Person

Skype or Other Video Conferencing

Other (specify)

35. Please describe any language or accommodation needs:

Educational History and Goals
36. Highest grade completed:
Primary or Secondary school
Vocational/Technical

Certificate

Some college

Graduate Equivalent (GED)
Undergrad

Graduate Degree

37. Describe any educational goal(s):

Employment history and financial goals:
38. Does the beneficiary want to eliminate benefits?

Yes

No

39. Does the beneficiary want to reduce dependence on benefits?

Yes

No

High School

Form SSA-4565 (06-2020)

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Employment goal(s):
40. Earning goal 1:
a. Type of position or field of work:
b. Number of hours anticipated per week:
c. Hourly wage or salary:
d. Estimated monthly earning goal:
41. Earning goal 2:
a. Type of position or field of work:
b. Number of hours anticipated per week:
c. Hourly wage or salary:
d. Estimated monthly earning goal:
42. Please list the employment services the beneficiary receives:
Agency

Service

Service

Employment Network
State VR
Other Employment Services
American Job Center
Vocational Training
Youth Transition Program
Other (specify below):

43. List the services the beneficiary needs to reach his or her employment goal:

Service

Form SSA-4565 (06-2020)

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44. Does the beneficiary want you to share the BS&A or other information about benefits advisement with
any employment support agency or other person? If yes, obtain release.
Yes
No
Employment Since Entitlement
45. Is the beneficiary currently employed or self-employed?

Yes

No

a. If "Yes," list the name of the beneficiary's Employer or beneficiary business

b. The beneficiary is

employed

self-employed

c. The employment or self-employment is

full-time

d. If employed, the amount of gross wages every

hour

part-time
week

year is

month

e. If employed, what weekday or dates does the employer issue the paycheck?
f. If the beneficiary is self-employed, what is the nature of the business:

g. What is the beneficiary's estimated net profit?
h. Has the beneficiary reported these earnings to Social Security?

Yes

No

i. If "Yes," give the date(s) of the report, and the manner he or she used to report the earnings:

Benefits at intake
46. SSA Benefits:
Benefit
SSI
SSDI
CDB
DWB
Other

Receiving

Comments

Form SSA-4565 (06-2020)

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47. Medicaid:
Benefit

Receiving

Recommended

Receiving

Recommended

Receiving

Recommended

SSI-based
1619(b)
Medicaid Home and Community-based
Waiver (specify)
Medicaid Spend-down
Medicaid Buy-in
Other Medicaid Program
48. Medicare:
Benefit
Part A
Part B
Medicare Savings Program (QMB/SLMB/
QI1) or other Medicare Buy-in group
Part D
Part D Low Income Subsidy
Premium HI for Working Disabled
49. Other Benefits:
Benefit
Employer or other Private Health
Insurance
Food Stamps (SNAP)
Housing Subsidy (Specify type)

Veteran's Compensation

Form SSA-4565 (06-2020)

Benefit

Page 7 of 9

Receiving

Recommended

Receiving

Recommended

Veteran's Pension
TANF
Unemployment Insurance
Worker's Compensation
Public Disability Benefit
Alimony or child support (specify)

Energy Assistance
SSI State Supplementation
Other (specify)

50. Excluded Savings
Benefit
Individual Development Account (IDA)
ABLE account
Trust
51. Additional Benefits (For example, benefits specific to your state)
Benefit

Comments

Form SSA-4565 (06-2020)

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52. List out of pocket expenses that could be Impairment Related Work Expenses (IRWE) or Blind Work
Expenses (BWE):

53. Describe special employment supports the beneficiary received in the past, currently uses, or expects to
need in the near future. Also describe any other indication that the beneficiary has a possible subsidy,
such as working with a job coach.

54. Notes, additional information and next steps:

Form SSA-4565 (06-2020)

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Privacy Act Statement
Collection and Use of Personal Information
Sections 1148 and 1149 of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information
is voluntary. However, failing to provide all or part of the information may limit your ability to participate in the Work Incentive
Planning and Assistance (WIPA) program.
We will use the information you provide to determine if you qualify for the WIPA program. We may also share your information for
the following purposes, called routine uses:
• To State or Employment Networks having an approved business arrangement with Social Security Administration (SSA)
to perform vocational rehabilitation services for SSA disability beneficiaries and recipients; and
• To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration
of its programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0295, entitled Ticket-to-Work
and Self-Sufficiency Program Payment Database, as published in the Federal Register (FR) on April 4, 2001, at 66 FR 17985, and
60-0300, entitled Ticket-to-Work Program Manager Management Information System, as published in the FR on June 15, 2001, at
66 FR 32656. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by
section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget (OMB) control number. We estimate that it will take about 20 minutes to read the instructions, gather
the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.