Information Collection

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

IC 9749 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⚠️ Notice: This information collection may be referencing outdated material.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
Form SSA-1021-INST (revised).pdf www.ssa.gov	Instruction
Form SSA-1021-INST (revised).pdf www.ssa.gov	Instruction
sample denial notice.pdf	Other-Sample Denial Letter
SSA-1021 Appeal of Determination for Help with Medicare Prescript Form SSA-1021 (revised).pdf www.ssa.gov	Form
SSA-1021 Appeal of Determination for Help with Medicare Prescript Form SSA-1021 (revised).pdf www.ssa.gov	Form
Form SSA-1021 (current).pdf Current SSA-1021	IC Document
Form SSA-1021 (current).pdf Current SSA-1021	IC Document
Form SSA-1021-INST (current).pdf SSA-1021- INST Instructions	IC Document
Form SSA-1021-INST (current).pdf SSA-1021- INST Instructions	IC Document

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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
Instruction			Form SSA-1021-INST (revised).pdf	www.ssa.gov	Yes	No	Printable Only
Form	SSA-1021	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs	Form SSA-1021 (revised).pdf	www.ssa.gov	Yes	No	Fillable Printable
Other-Sample Denial Letter			sample denial notice.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: 2,872

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	2,872	-411	3,283
Annual IC Time Burden (Hours)	479	-68	547
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-1021	Form SSA-1021 (current).pdf	10/01/2020
SSA-1021- INST Instructions	Form SSA-1021-INST (current).pdf	10/01/2020

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