Form SSA-4565 WIPA Intake Information

Form SSA-4565 (XX-XXXX)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0629

Help Line Work Incentives Planning and Assistance (WIPA)
Referral and WIPA Intake (SSA-4565)

Instructions: Use Acrobat to open and save this form to retain accessibility features. Help Line
representatives should complete items 1-20, and Work Incentives Planning and Assistance
(WIPA) Community Work Incentives Coordinators (CWICs) should complete items 21-66. If the
referral does not come from the Help Line, CWICs should complete the entire form. CWICs
must complete this form. Beneficiaries should not complete it themselves.
1. Date of contact:
3. a. Previously referred?

2. Servicing WIPA:
Yes

No

b. If yes, date:

4. Name (first, middle, last):
5. a. Address (include city, state and ZIP):

b. County:
b. Work phone:

6. a. Cell phone:

d. Teletype (TTY/TDD)/Videophone number/Internet
Protocol (IP) address:

c. Home phone:
7. Email address:
8. Best time and number to call:
9. a. Beneficiary's preferred language:

English

Other

b. If "Other", specify
10. a. Representative Payee?

Yes

No

If yes, complete 10b - e:

b. Representative Payee name (first, middle, last):
c. Representative Payee address (include city, state and ZIP):

d. Representative Payee phone:
e. Representative Payee email:
11. Social Security Number (SSN) :
12. Claim number (if different from beneficiary SSN):
13. Date of birth:

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14. Is the beneficiary between the ages of 14 and 25 at the time of referral?

Yes

No

15. Is the beneficiary a Veteran of the United States Military?

Yes

No

16. Type of benefits received by the beneficiary (verified by iTOPSS):
Supplemental Security Income (SSI)
Title II (Social Security Disability Insurance (SSDI) (Includes: Childhood Disability Benefits (CDB)
and Disabled Widow(er)s Benefits (DWB))
Concurrent entitlement (SSI and SSDI)
17. a. Ticket status (if over 18): b. If assigned/in-use with Vocational Rehabilitation agency, agency name:

18. a. Employment status:
Full-time employment or self-employment
Part-time employment or self-employment
Job offer pending
Not employed
b. If employed, job details (job title, # hours/week, pay rate):

c. Employer health benefits?

Yes

No

Not Applicable(N/A)

d. Reported work to Social Security Administration (SSA)?

Yes

No

N/A

Yes

No

N/A

19 a. Other benefits received?
b. If "Yes", specify

20. Beneficiary concerns/questions:

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WIPA Intake Information
21. Date of referral:
22. Source of referral:
Ticket to Work Help Line
Beneficiary or Representative Payee self-referral
Vocational Rehabilitation agency
Employment Network
Other community agency
23. Beneficiary Unique Identifier:
24. CWIC:
25. Local SSA Field Office:

Additional Demographics
26. a. Primary contact:
Beneficiary

Representative Payee

Guardian

Other

b. If "Other", specify
27. a. Is the Representative Payee the legal guardian?

Yes

No

If there is a legal guardian who is not the representative payee, complete lines 27 b-e.
b. Legal guardian name (first, middle, last):
c. Legal guardian address:
d. Legal guardian phone:
e. Legal guardian email:
28. a. Preferred method of contact for primary contact:
Telephone
Skype or other video conferencing
b. If "Other", specify
29. a. Alternate contact:

Representative Payee

Guardian

b. If "Other", specify relationship and complete lines 29 c-f
c. Alternate contact name:
d. Alternate contact address:

e. Alternate contact phone:
f. Alternate contact email:

In-person

Email
Via an interpreter

Other

Other

Form SSA-4565 (XX-XXXX)

30. a. Preferred method of contact for alternate contact:
Telephone
Email
Skype or other video conferencing
Via an interpreter

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In-person
Other

b. If "Other", specify
31. Describe any language or accommodation needs:

32. If over age 18 and receiving SSI, has Social Security conducted the age 18 redetermination?
Yes
No
33. When did the disability begin?
Prior to age 22
Between age 22 and prior to age 26
Age 26 or older
34. Does the beneficiary have a my Social Security account?
Yes
No
Recommended
35. List the primary disability:
36. Statutorily Blind?
Yes

No

37. Marital Status:
Single

Married

Divorced

Separated

Widow(er)

38. Race (choose all that apply):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefers not to provide
39. Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Prefers not to provide
40. Sex:
Male
Female
Other
41. List other people in the household:
Receiving
Name / Relationship
Age
Type of Benefit
Amount
Comments
Benefits?
Yes

No

Yes

No

Yes

No

Yes

No

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

43. For SSI and Medicaid recipients only, describe all income or in-kind support:
Type of Income/ In-Kind Support

Source

Amount

Benefits at Intake
44. a. Health insurance:
Medicare (list parts in 44b.)
Employer-sponsored
b. Health insurance notes:

Medicaid (list type in 44b.)
Veteran's Affairs

Private
Other (describe in 44b.)

None

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45. SSA benefits:
Benefit

Receiving

Amount

Comments

SSI
SSDI
CDB
DWB
Other
46. a. Medicaid number (if applicable):
b. Medicaid benefits:
Benefit
SSI-based
1619 (b)
Medicaid Home and
Community-based
Waiver
(specify in comments)
Medicaid Spend-down
Medicaid Buy-in
Other Medicaid Program
(specify in comments)

Receiving Recommended

Comments

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47. a. Medicare number (if different than SSN):
b. Medicare benefits:
Benefit

Receiving Recommended

Comments

Part A
Part B
Medicare Savings Program (Qualified
Medicare Beneficiary (QMB)/Special LowIncome Medicare Beneficiary (SLMB)/
Qualified Individual (QI) or other Medicare
Buy-in group
Medicare Advantage Plan – Part C
(specify in comments)
Part D
Part D Low Income Subsidy (full / partial)
Premium Health Insurance (HI) for the
Working Disabled
48 . Other Benefits:
Benefit
Employer or other private health insurance
(specify type)
Food stamps
(Supplemental Nutrition Assistance Program (SNAP))
Housing subsidy
(specify type)
Veteran’s compensation
Veteran’s pension
Temporary Aid to Needy Families (TANF)
Unemployment insurance
Worker’s compensation
Public disability benefit
Alimony or child support
(specify)
Energy assistance
SSI State Supplementation
Other
(specify)

Receiving

Amount
Recommended
(if applicable)

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49. Excluded savings:
Benefit

Receiving Recommended

Individual Development Account (IDA)
Achieving a Better Life Experience (ABLE) Account
Trust
Property Essential for Self Support (PESS)
50. Additional benefits or assets (for example, benefits specific to your state):
Benefit/Asset

Amount
(if applicable)

51. Eligible for WIPA services?

Comments

Yes

No

Educational History and Goals
52. Highest grade completed:
Primary or secondary school
High school diploma
Undergraduate degree

Certificate
Vocational/technical
Graduate degree

Graduate equivalent (GED)
Some college

53. a. If under age 22, is the beneficiary regularly attending school?

Yes

No

b. If “Yes”, is the Student Earned Income Exclusion applicable?

Yes

No

Not Applicable

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54. Describe any educational goal(s):

Employment history and financial goals:
55. a. Does the beneficiary want to (choose one):
Increase income without losing SSDI or SSI benefits
Reduce SSDI or SSI benefits
Eliminate SSDI or SSI benefits
b. Comments on work goals

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Employment goal(s):
56. 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:
57. 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:
58. Employment services the beneficiary receives:
Agency
Employment Network
(specify name)

Vocational Rehabilitation
Other Employment Services
(specify name)

American Job Center
Vocational Training
(specify name)
Youth Transition Program
(specify name)
Other (specify below):

Contact

Service(s)

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

60. Does the beneficiary want you to share the Benefits Summary and Analysis (BS&A) or other information
about benefits counseling with any employment support agency or other person? If yes, obtain
release.
Yes
No
61. BS&A delivery:
a. Beneficiary:
Telephone
Email
Skype or other video conferencing
b. If "Other", specify

US mail
Via an interpreter

In-person
Other

US mail
Via an interpreter

In-person
Other

c. Alternate Contact:
Telephone
Email
Skype or other video conferencing
d. If "Other", specify

Employment Since Entitlement
62. a. Employment status at the time the CWIC begins providing individualized services
Full-time employment or self-employment
Job offer pending
If job offer pending or not employed skip to #63

Part-time employment or self-employment
Not employed

b. Start date of current employment or self-employment:
c. If employed, name of employer:
d. If employed, weekday or dates employer issue paychecks
hour
week
e. If employed, the amount of gross wages per
f. If self-employed, nature of the business

g. If self-employed, estimated net profit

month

year is

(enter amount)

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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:

63. Prior Work History:
Employer/Job title

Hours/week

Rate of pay

Dates of
Employment

Comments

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

65. 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.

Form SSA-4565 (XX-XXXX)

66. Notes, additional information and next steps:

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Form SSA-4565 (XX-XXXX)

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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.