Ssa-9301

Medicare Subsidy Quality Review

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0707 can be found here:

Documents and Forms

Document Name Document Type
SSA-9301 (revised).pdf N/A conducted over telephone Other-Telephone Interview Script
ssa9301 (current).pdf SSA-9301 Current Version IC Document

Information Collection (IC) Details

IC Title:	SSA-9301	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 418(b)(5) (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Telephone Interview Script			SSA-9301 (revised).pdf	N/A conducted over telephone	No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	1,750	1,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-9301 Current Version	ssa9301 (current).pdf	10/04/2017

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