Information Collection

Paper Form (mailed)

IC 195114 under ICR 201011-0960-002 · OMB 0960-0784.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0784 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-44 Paper Form (mailed) Form and Instruction
SSA-44 Medicare Income-Related Monthly Adjustment Amount - Life SSA-44.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Paper Form (mailed)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 418.2265 20 CFR 418.1205 20 CFR 418.1255 20 CFR 418.1265 20 CFR 418.2205 20 CFR 418.2255

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-44	Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event	SSA-44.pdf		No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 39,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	39,000	39,000
Annual IC Time Burden (Hours)	29,250	29,250
Annual IC Cost Burden (Dollars)	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.