Information Collection

Appeal of Determination for Help with Medicare Prescription Drug Plan Costs

IC 9749 under ICR 200908-0960-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Form SSA-1021 new version.pdf	Form and Instruction
Form SSA-1021 old version.pdf Old version of SSA-1021	IC Document

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	Form SSA-1021 new version.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
Old version of SSA-1021	Form SSA-1021 old version.pdf	08/25/2009

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