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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.