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

Medicare Part B Income-Related Premium -- Life-Changing Event

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

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: 20 CFR 418.1205 20 CFR 418.1255 20 CFR 418.1265

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: 139,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	139,000	11,000	128,000
Annual IC Time Burden (Hours)	69,500	5,500	64,000
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.