WIPA Beneficiary/Recipient Application

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WIPA Beneficiary/Recipient Application (OMB No. 0960-0629)

WIPA Program Identification Code: _________    Benefit Specialist Code: ___________

Community Work Incentives Coordinator Name: _________________________

    Date of Intake (mm/dd/yyyy)     Date of Update (mm/dd/yyyy)

Demographic Information:

    Last Name   First Name   Middle Inital

    SSN - -

    Address

    Zip Code

    Phone ( ) -

    Date of Birth (mm/dd/yyyy) / /

    Is the Date of Birth an Estimated Date?    Yes   No

1. Gender   Female   Male

2. Primary Disability at Intake

     (1) Blind or Visual Impairment

     (2) Hearing, Speech, and other Sensory Impairments

     (3) Spinal Cord Injury

     (4) Non-Spinal Cord Orthopedic Disabilities/Amputations/Motor Impairments

     (5) Mental and Emotional Disorders

     (6) Cognitive/Developmental Disabilities

     (7) System Diseases (e.g. nervous, endocrine, cardiac, etc.)

     (8) Traumatic Brain Injury

• (9) Infectious Disease

10. Injury

(11) Cancer/Neoplasm

     (12) Other ( Must specify: )

3. Special Language or Other Considerations at Intake (Check all that apply)

     Sign Language

     English as a Second Language

     Other  

4. Current Benefit(s) at Intake (Check all that apply)

     SSI

     SSDI

     Concurrent SSI/SSDI

     Medicare

     Medicaid

     Private Health Insurance

     Subsidized Housing

     Food Stamps

     TANF

     Workers Compensation

     Unemployment Insurance

     Veterans Benefit

     Other

5. Current Employment Status at Intake

     (1) Employed Full-Time

     (2) Employed Part-Time

     (3) Not Employed, Seeking Employment

     (4) Not Employed, Not Seeking Employment

Service Related Questions:

6. Reason for service request (Check all that apply)

     Responded to outreach from WIPA program

     Communication from SSA

     Responded to Ticket to Work Communication from SSA

     Not working, but considering going to work

     Working, and considering/anticipating change in employment status

     Contacted Program as a result of actual change experienced in employment status

         (1) lost job   (2) starting new job   (3) increase/decrease in salary

     Anticipated or actual change experienced in other financial or life factors
           (including other benefits, health care coverage, living arrangement, marital status...)

     Other

7. Service(s) delivered (Check all that apply)

     Information and Referral

     Problem Solving and Advocacy

     Benefits Analysis and Advisement

     Benefits Support Planning

     Benefits Management

8. Recommended Incentives to be Used (Check all that apply)

     TWP

     EPE

     PASS

     IRWE

     1619 (a)

     1619 (b)

     Medicaid Buy-In

     Blind Work Expense

     Student Earned Income Exclusion

     Subsidy Development

     Extended Medicare

9. Recommended Provisions to be Used (Check all that apply)

     Property Essential to Self Support

     Expedited Reinstatement of Benefits

     Ticket to Work Program

     Continuing Disability Review (CDR) Protections

     Section 301

     Unsuccessful Work Attempt

10. Anticipated Employment Status Change

     (1) Does not intend to change current employment status

     (2) Intends to seek new job or supplemental job

     (3) Intends to increase work hours in current job

     (4) Intends to decrease work hours in current job

     (5) Intends to cease employment

     (6) Made no decision

    10a. Intends to use Ticket to Work to seek new or supplemental job (check if Yes)

    10b. Intends to pursue education or training (check if Yes)

11. What is the approximate TOTAL amount of time spent working with or for the participant thus far

     (1) Less than 1 hour

     (2) One hour or more ( Specify TOTAL in whole hours: )

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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 control number.  We estimate that it will take about 5 minutes to read the instructions, gather the facts, and answer the questions.  You may send comments on our time estimate above to:  SSA, 6401 Security Blvd, Baltimore, MD  21235-6401.  Send only comments relating to our time estimate to this address, not the completed form.

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