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

Application for Help with Medicare Prescription Drug Plan Costs

Documents and Forms

Document Name Document Type
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

Information Collection (IC) Details

IC Title:	Application for Extra Help With Medicare Prescription Drug Plan Costs (field office interview)	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
Other-Screens for SSA field office interview			1020 MAPS Field Office Screens.pdf		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 %

	Requested	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)	42,937	-11,160	54,097
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current MAPS Screens	1020 MAPS Field Office Screens (current).pdf	03/05/2021

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