Information Collection

Appeal of Determination for Help with Medicare Prescription Drug Plan Costs

IC 9749 under ICR 200712-0960-002 · OMB 0960-0695.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0695 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
096-0695 APPEAL SCRNS.doc	Other-Screens used by SSA employees
SSA-1021 Appeal of Determination for Help with Medicare Prescript ssa-1021.pdf	Form and Instruction

IC Title:

Appeal of Determination for Help with Medicare Prescription Drug Plan Costs

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 418.3101

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screens used by SSA employees for completion during personal interview vs. paper completion			096-0695 APPEAL SCRNS.doc		Yes	No	Fillable Fileable
Form and Instruction	SSA-1021	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs	ssa-1021.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 75,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	75,000	75,000
Annual IC Time Burden (Hours)	12,500	12,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.