Information Collection

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

IC 227171 under ICR 202008-0960-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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
0960-0695 Revised MAPS MEDQ.pdf	Other-Intranet Screens
0960-0695 Revised MAPS MEDQ.pdf	Other-Intranet Screens

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: Modified

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					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: 9,691

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	9,691	-1,346	11,037
Annual IC Time Burden (Hours)	1,615	-225	1,840
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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