Appeal of Determination for Help with Medicare Prescription Drug Plan Costs

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0695 can be found here:

Documents and Forms

Document Name Document Type
096-0695 APPEAL SCRNS.doc Other-Screens used by SSA employees
SSA-1021 Appeal of Determination for Help with Medicare Prescript SSA-1021 Form and Inst.pdf Form and Instruction
ssa-1021.pdf Old version of SSA-1021 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screens used by SSA employees for completion during personal interview vs. paper completion			096-0695 APPEAL SCRNS.doc		Yes	No	Fillable Fileable
Form and Instruction	SSA-1021	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs	SSA-1021 Form and Inst.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: 75,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 30 %

	Approved	Previously Approved
Annual Number of Responses for this IC	75,000	75,000
Annual IC Time Burden (Hours)	12,500	12,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Old version of SSA-1021	ssa-1021.pdf	09/21/2010

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