Information Collection

Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - Paper Version

IC 9749 under ICR 202312-0960-004 · OMB 0960-0695.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SSA-1021 INST (Revised).pdf	Instruction
sample denial notice.pdf	Other-Sample Denial Letter
SSA-1021 PA Statement (Revised).pdf	Other-Privacy Act Statement (revised
SSA-1021 Appeal of Determination for Help with Medicare Prescript SSA-1021 (Revised).pdf	Form
ssa-1021(Current).pdf Current SSA-1021	IC Document
ssa-1021-inst (Current).pdf SSA-1021- INST Instructions	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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
Instruction			SSA-1021 INST (Revised).pdf	www.ssa.gov	Yes	No	Printable Only
Form	SSA-1021	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs	SSA-1021 (Revised).pdf	www.ssa.gov	Yes	No	Fillable Printable
Other-Sample Denial Letter			sample denial notice.pdf		No		Paper Only
Other-Privacy Act Statement (revised)			SSA-1021 PA Statement (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: 1,859

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,859	-1,013	2,872
Annual IC Time Burden (Hours)	620	141	479
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-1021	ssa-1021(Current).pdf	12/28/2023
SSA-1021- INST Instructions	ssa-1021-inst (Current).pdf	12/28/2023

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