Form SSA-4565 WIPA Intake Information

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
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.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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.