Information Collection

Medicare Part B Income-Related Premium -- Life-Changing Event (screen shots)

IC 45499 under ICR 200906-0960-001 · OMB 0960-0735.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0735 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screen Shots of LCE (2).doc completed in field office on-screen by SSA employee	Other-MSSICS Screens

IC Title:

Medicare Part B Income-Related Premium -- Life-Changing Event (screen shots)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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-MSSICS Screens			Screen Shots of LCE (2).doc	completed in field office on-screen by SSA employee	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: 128,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	128,000	59,510	68,490
Annual IC Time Burden (Hours)	64,000	-4,490	68,490
Annual IC Cost Burden (Dollars)	0	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.