Form SSA-4566 WIPA Case Notes

Form SSA-4566 (XX-2018)
Social Security Administration

Page 1 of 5
OMB No. 0960-0629

WIPA Case Notes
Beneficiary:
Date of contact:
Person contacted:
Purpose of the contact:
What work incentives, health care options, or other benefits did you discuss?

List any referrals you made to other agencies:

Notes and next steps:

Date of contact:
Person contacted:
Purpose of the contact:
What work incentives, health care options, or other benefits did you discuss?

Form SSA-4566 (XX-2018)

List any referrals you made to other agencies:

Notes and next steps:

Date of contact:
Person contacted:
Purpose of the contact:
What work incentives, health care options, or other benefits did you discuss?

List any referrals you made to other agencies:

Notes and next steps:

Page 2 of 5

Form SSA-4566 (XX-2018)

Date of contact:
Person contacted:
Purpose of the contact:
What work incentives, health care options, or other benefits did you discuss?

List any referrals you made to other agencies:

Notes and next steps:

Date of contact:
Person contacted:
Purpose of the contact:
What work incentives, health care options, or other benefits did you discuss?

List any referrals you made to other agencies:

Page 3 of 5

Form SSA-4566 (XX-2018)

Notes and next steps:

Date of contact:
Person contacted:
Purpose of the contact:
What work incentives, health care options, or other benefits did you discuss?

List any referrals you made to other agencies:

Notes and next steps:

Page 4 of 5

Form SSA-4566 (XX-2018)

Date

Page 5 of 5

Item
BSA
BSA
BSA
BSA
WIP
WIP
WIP
WIP

Not Needed

In Process

Completed