Internet Application for Help with Medicare Prescription Drug Plan Costs

Application for Help with Medicare Prescription Drug Plan Costs

Documents and Forms

Document Name Document Type
Form i1020 Internet Application for Help with Medicare Prescription Drug Plan Costs Form and Instruction
i1020 Internet Application for Extra Help with Medicare Prescr i1020 Online Application Screens.pdf www.socialsecurity.gov Form and Instruction
i1020 Online Application Screens.pdf Current i1020 screen shots IC Document

Information Collection (IC) Details

IC Title:	Internet Application for Help with Medicare Prescription Drug Plan Costs	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 418.3101

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	i1020	Internet Application for Extra Help with Medicare Prescription Drug Plan Costs	i1020 Online Application Screens.pdf	http://www.socialsecurity.gov	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: 365,871	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	365,871	19,229	346,642
Annual IC Time Burden (Hours)	152,446	8,012	144,434
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current i1020 screen shots	i1020 Online Application Screens.pdf	06/01/2021

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