Application for Help with Medicare Prescription Drug Plan Costs (Paper Form)

Application for Help with Medicare Prescription Drug Plan Costs

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0696 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-1020 Application for Help with Medicare Prescription Drug Plan Costs (Paper Form) Form and Instruction
SSA-1020 Application for Help with Medicare Prescription Drug Pla SSA-1020B-OCR-SM-INST MLN 122111(revised).pdf Form and Instruction
SSA-1020B-OCR-SM-INST MLN 083111 (current).pdf SSA-1020 (current) IC Document

Information Collection (IC) Details

IC Title:	Application for Help with Medicare Prescription Drug Plan Costs (Paper Form)	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 418.3101

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-1020	Application for Help with Medicare Prescription Drug Plan Costs	SSA-1020B-OCR-SM-INST MLN 122111(revised).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: 724,238	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	724,238	164,238	560,000
Annual IC Time Burden (Hours)	362,119	82,119	280,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-1020 (current)	SSA-1020B-OCR-SM-INST MLN 083111 (current).pdf	10/03/2011

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