Information Collection

Paper Form (mailed)

IC 195114 under ICR 201101-0960-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form SSA-44 Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event Paper Form (mailed)	Form and Instruction
SSA-44 Medicare Income-Related Monthly Adjustment Amount - Life SSA-44.pdf	Form and Instruction

IC Title:

Paper Form (mailed)

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 20 CFR 418.2265 20 CFR 418.2205 20 CFR 418.2255

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-44				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 %

table that charts list of burden
	Approved	Previously Approved
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

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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].