SSA-1026-SCE - Reporting a Change That May Affect Your Extra Help

Redetermination of Eligibility for Help with Medicare Prescription Drug Plan Costs

Documents and Forms

Document Name Document Type
Form SSA-1026-SCE SSA-1026-SCE - Reporting a Change That May Affect Your Extra Help Form and Instruction
i1026 Application Screen Shots.pdf Other-i1026 Intranet Screens
SSA-1026-SCE SSA - Reporting a Change That May Affect Your Extra Help SSA-1026-SCE - Revised.pdf Form and Instruction
SSA-1026 SCE - Current.pdf SSA-1026-SCE - Current Version IC Document

Information Collection (IC) Details

IC Title:	SSA-1026-SCE - Reporting a Change That May Affect Your Extra Help	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 418.3125

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-1026-SCE	SSA - Reporting a Change That May Affect Your Extra Help	SSA-1026-SCE - Revised.pdf		No		Fillable Printable
Other-i1026 Intranet Screens			i1026 Application Screen Shots.pdf		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: 3,462	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,462	-805	4,267
Annual IC Time Burden (Hours)	1,039	-241	1,280
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-1026-SCE - Current Version	SSA-1026 SCE - Current.pdf	03/08/2021

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