Form SSA-4567 Help Line WIPA Referral

Form SSA-4567 (XX-2018)
Social Security Administration

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OMB No. 0960-0629

Help Line WIPA Referral
1. Date of Contact:
3. Previously referred?

2. Date of Referral:
Yes

No

4. Name:
5. Address (include city, state, and ZIP):

6. County:
7. a. Cell Phone:

b. Work Phone:

c. Home Phone:

d. TTY/Videophone Number/IP Address:
8. Email Address:
9. Best time and number to contact?
Other (specify):

English

10. Beneficiary's preferred language:
11. Date of Birth:

12. The beneficiary is a transition age youth (under age 25)?
13. The beneficiary is a Veteran of the U.S. Military?

Yes

Yes

No

No

14. SSN:
15. Type of benefits received by the beneficiary (verified by iTOPSS):
SSI

Title II (SSDI, CDB, DWB)

Concurrent entitlement (SSI and SSDI)

16. Ticket Status (if over 18):
17. a. Employment Status:
b. Job details (job title, # hours/week, pay rate):

c. Employer Health Benefits?
d. Reported work to SSA?

Yes
Yes

No
No

Form SSA-4567 (XX-2018)

18. Other benefits received?

19. Beneficiary concerns/questions:

If the beneficiary has a payee:
20. a. Representative Payee name:
b. Payee Phone:
c. Payee Email:

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