Information Collection

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

IC 45499 under ICR 201006-0960-013 · OMB 0960-0735.

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:

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:

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: 139,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	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

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.