Medicare Part B Income-Related Premium -- Life-Changing Event (paper form)

Medicare Part B Income-Related Premium -- Life-Changing Event

Documents and Forms

Document Name Document Type
Form SSA-44 Medicare Part B Income-Related Premium -- Life-Changing Event (paper form) Form and Instruction
SSA-44 Medicare Part B Income-Related Premium - Life-Changing E SSA-44 - Revised Version.pdf www.socialsecurity.gov Form and Instruction
Form_SSA-44_Revised[1].pdf Previous SSA-44 IC Document

Information Collection (IC) Details

IC Title:	Medicare Part B Income-Related Premium -- Life-Changing Event (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 418.1205 20 CFR 418.1255 20 CFR 418.1265

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-44	Medicare Part B Income-Related Premium - Life-Changing Event	SSA-44 - Revised Version.pdf	http://www.socialsecurity.gov	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 37,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	37,000	5,000	32,000
Annual IC Time Burden (Hours)	27,750	3,750	24,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Previous SSA-44	Form_SSA-44_Revised[1].pdf	06/29/2010

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