Personal Interview (SSA Field Office)

Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event

Documents and Forms

Document Name Document Type
IRMAA Screens.pdf Other-Intranet Screens
0784 PRA (revised).pdf Other-Revised Privacy Act Statement
0784 Privacy Act Statement (revised).pdf Other-0784 Privacy Act Statement

Information Collection (IC) Details

IC Title:	Personal Interview (SSA Field Office)	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 418.1265 20 CFR 418.2255 20 CFR 418.2265 20 CFR 418.1255 20 CFR 418.2205 20 CFR 418.1205

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Intranet Screens	IRMAA Screens.pdf	Yes	Yes	Fillable Fileable Signable
Other-Revised Privacy Act Statement	0784 PRA (revised).pdf	Yes	Yes	Printable Only
Other-0784 Privacy Act Statement	0784 Privacy Act Statement (revised).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: 178,840	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	178,840	38,462	140,378
Annual IC Time Burden (Hours)	89,420	19,231	70,189
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.