Application for Help with Medicare Prescription Drug Plan Costs (Paper Form)

Application for Help with Medicare Prescription Drug Plan Costs

Documents and Forms

Document Name Document Type
Form SSA-1020 Application for Help with Medicare Prescription Drug Plan Costs (Paper Form) Form and Instruction
SSA-1020 Application for Help with Medicare Prescription Drug Pla SSA-1020 (revised).pdf Form and Instruction
SSA-1020 (current).pdf SSA-1020 - Current IC Document

Information Collection (IC) Details

IC Title:	Application for Help with Medicare Prescription Drug Plan Costs (Paper Form)	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	SSA-1020	Application for Help with Medicare Prescription Drug Plan Costs	SSA-1020 (revised).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 448,836	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	448,836	-82,879	531,715
Annual IC Time Burden (Hours)	224,418	-41,440	265,858
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-1020 - Current	SSA-1020 (current).pdf	03/05/2021

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