Information Collection

Application for Extra Help With Medicare Prescription Drug Plan Costs (field office interview)

IC 187636 under ICR 202102-0960-001 · OMB 0960-0696.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
1020 MAPS Field Office Screens.pdf	Other-Screens for SSA field office i
1020 MAPS Field Office Screens.pdf	Other-Screens for SSA field office i
1020 MAPS Field Office Screens (current).pdf Current MAPS Screens	IC Document
1020 MAPS Field Office Screens (current).pdf Current MAPS Screens	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 418.3101

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
Other-Screens for SSA field office interview					No		Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 85,873

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	85,873	-22,321	108,194
Annual IC Time Burden (Hours)	120,222	66,125	54,097
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current MAPS Screens		03/05/2021

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

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