Information Collection

Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - MAPS Intranet Version

IC 227171 under ICR 201703-0960-013 · OMB 0960-0695.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0695 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MAPS Appeals Screenshots - Revised Version.pdf	Other-Intranet Screens
SSA-1021 - Revised PA Statement.pdf	Other-Revised Privacy Act Statement
MAPS Appeals Screenshots - Current Version.pdf Current MAPS Screens	IC Document

IC Title:

Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - MAPS Intranet Version

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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
Other-Intranet Screens			MAPS Appeals Screenshots - Revised Version.pdf		Yes	Yes	Fillable Fileable Signable
Other-Revised Privacy Act Statement			SSA-1021 - Revised PA Statement.pdf		Yes	Yes	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11,037

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
Annual Number of Responses for this IC	11,037	11,037
Annual IC Time Burden (Hours)	1,840	1,840
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current MAPS Screens	MAPS Appeals Screenshots - Current Version.pdf	06/13/2017

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