Information Collection

Paper Form (mailed)

IC 195114 under ICR 201401-0960-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Paper Form (mailed)	Form and Instruction
SSA-44 Medicare Income-Related Monthly Adjustment Amount - Life SSA-44 Revised Version.pdf	Form and Instruction
SSA-44 Current Version.pdf SSA-44 Current Version	IC Document

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

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	Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event	SSA-44 Revised Version.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 %

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
SSA-44 Current Version	SSA-44 Current Version.pdf	02/20/2014

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