Information Collection

Paper Form SSA-44 (mailed or fillable PDF)

IC 195114 under ICR 202010-0960-002 · OMB 0960-0784.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-44 Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event Paper Form SSA-44 (mailed or fillable PDF)	Form and Instruction
0784 Privacy Act Statement (revised).docx	Other-0784 Privacy Act Statement (re
0784 Privacy Act Statement (revised).docx	Other-0784 Privacy Act Statement (re
0784 PRA (revised).pdf	Other-0784 PRA Statement
0784 PRA (revised).pdf	Other-0784 PRA Statement
SSA-44 Medicare Income-Related Monthly Adjustment Amount - Life SSA-44 (revised).pdf	Form and Instruction
SSA-44 Medicare Income-Related Monthly Adjustment Amount - Life SSA-44 - Revised (6-11-21).pdf	Form and Instruction
SSA-44 (current).pdf SSA-44 - Current	IC Document
SSA-44 (current).pdf SSA-44 - Current	IC Document

IC Title:

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 418.2265 20 CFR 418.2205 20 CFR 418.2255 20 CFR 418.1205 20 CFR 418.1255

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-44	No		Fillable Printable
Other-0784 Privacy Act Statement (revised)		Yes	No	Printable Only
Other-0784 PRA Statement		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 76,645

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	76,645	16,483	60,162
Annual IC Time Burden (Hours)	57,484	12,362	45,122
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-44 - Current		10/01/2020

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

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