Embarking on the journey of understanding the SSA-4290-F4 form is essential for individuals engaged in vocational rehabilitation or similar programs through the Social Security Administration (SSA). This form acts as a bridge between beneficiaries and the support they receive, ensuring their participation in various rehabilitation or employment services is accurately documented and communicated to the SSA. Primarily utilized by State Disability Determination Services (DDS) or SSA Field Offices, the form collects comprehensive beneficiary information, ranging from personal details to specifics about the vocational rehabilitation services or similar programs they are receiving. It outlines a structured way to report on the type of claim, beneficiary’s personal information, and the details of the vocational rehabilitation or similar program, including the involved agency and contact information. Filling out this form accurately is crucial for beneficiaries, as it can impact their eligibility and the continuity of their benefits. Its importance extends beyond mere documentation, serving as a vital link in supporting individuals' journey towards employment and independence, thereby fostering their participation in society.
| Question | Answer |
|---|---|
| Form Name | Ssa 4290 F4 Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | OMB, ssa 4290, Page1, 01r |
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Form Approved |
SOCIAL SECURITY ADMINISTRATION |
OMBNo. |
DEVELOPMENT OF PARTICIPATION IN A
VOCATIONAL REHABILITATION OR SIMILAR PROGRAM
Part I
Section A
1. Beneficiary's |
Name |
(Last, First, MI) |
2. Beneficiary's |
Date |
3. Type of claim |
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of Birth |
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r 01r 551 r Concurrent |
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4. Beneficiary's |
Social |
Security Number |
5. Wage |
Earner's |
Social Security Number |
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(if different |
from Beneficiary's) |
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6.Beneficiary's address (Number & Street, City, State, Zip Code)
7.Beneficiary reports that he/she is receiving vocational rehabilitation services, employment services, or other support services from (check one):
An Employment Network under an Individual Work Plan (IWP)
A State Vocational Rehabilitation agency under an Individualized Plan for
Employment (IPE)
Other provider of services under an individualized, written employment plan similar to an IPE
An educational institution under an Individualized Education Program (IEP) to beneficiary age 18 through 21 years
8.Name, address and telephone number of a contact person in the organization/agency identified above:
Section B
9. Signature of Person Who Completed Part I: |
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10. Title: |
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11. |
Date: |
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12. DDS |
or Fa Code: |
13. |
Telephone |
number |
( |
) |
- |
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(include area |
code): |
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Form |
Page1 |