Information Collection

Internet Application for Help with Medicare Prescription Drug Plan Costs

IC 182917 under ICR 201409-0960-010 · OMB 0960-0696.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form i1020 Internet Application for Help with Medicare Prescription Drug Plan Costs	Form and Instruction
i1020 Internet Application for Extra Help with Medicare Prescr Revised i1020 screens 2015.pdf www.socialsecurity.gov	Form and Instruction
Current i1020 screens].docx Current i1020 screen shots	IC Document

IC Title:

Internet Application for Help with Medicare Prescription Drug Plan Costs

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:

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	i1020	Internet Application for Extra Help with Medicare Prescription Drug Plan Costs	Revised i1020 screens 2015.pdf	http://www.socialsecurity.gov	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: 282,228

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	282,228	-126,961	409,189
Annual IC Time Burden (Hours)	117,595	-52,900	170,495
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current i1020 screen shots	Current i1020 screens].docx	10/07/2014

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