Information Collection

Paper Form SSA-44 (mailed or fillable PDF)

IC 195114 under ICR 201703-0960-015 · 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⚠️ Notice: This information collection may be referencing outdated material.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 SSA-44 (mailed or fillable PDF)	Form and Instruction
Revised PA and PRA Statements - SSA-44.pdf	Other-Revised Privacy Act and PRA St
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 SSA-44 (mailed or fillable PDF)

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
Other-Revised Privacy Act and PRA Statements			Revised PA and PRA Statements - SSA-44.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: 60,162

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	60,162	21,162	39,000
Annual IC Time Burden (Hours)	45,122	15,872	29,250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-44 Current Version	SSA-44 - Current Version.pdf	06/09/2017

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