Internet Application for Help with Medicare Prescription Drug Plan Costs

Application for Help with Medicare Prescription Drug Plan Costs

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0696 can be found here:

Documents and Forms

Document Name Document Type
Form i1020 Internet Application for Help with Medicare Prescription Drug Plan Costs Form and Instruction
i1020 Internet Application for Help with Medicare Prescription new i1020 screen shots.pdf www.ssa.gov Form and Instruction

Information Collection (IC) Details

IC Title:	Internet Application for Help with Medicare Prescription Drug Plan Costs	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 418.3101

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	i1020	Internet Application for Help with Medicare Prescription Drug Plan Costs	new i1020 screen shots.pdf	www.ssa.gov	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 585,222	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	585,222	585,222
Annual IC Time Burden (Hours)	438,917	438,917
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.