Information Collection

Application for Help with Medicare Prescription Drug Plan Costs (Paper Form)

IC 38067 under ICR 200907-0960-002 · OMB 0960-0696.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1020 Application for Help with Medicare Prescription Drug Plan Costs (Paper Form)	Form and Instruction
SSA-1020 Application for Help with Medicare Prescription Drug Pla NEW 1020 (1-15-09).pdf	Form and Instruction
Old SSA-1020.pdf Current Paper SSA-1020 (to be used through 2009)	IC Document

IC Title:

Application for Help with Medicare Prescription Drug Plan Costs (Paper Form)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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
Form and Instruction	SSA-1020	Application for Help with Medicare Prescription Drug Plan Costs	NEW 1020 (1-15-09).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: 560,000

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	560,000	560,000
Annual IC Time Burden (Hours)	280,000	280,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current Paper SSA-1020 (to be used through 2009)	Old SSA-1020.pdf	12/22/2008

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