Ssa-9303

Medicare Subsidy Quality Review

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0707 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-9303 SSA-9303 Form and Instruction
Revised SSA-9304 Checklist of Required Information.pdf Instruction
SSA-9303 Notice of Appointment-Please Call Reviewer Revised SSA-9303 Notice of Appointment - Please Call Reviewer.pdf Form and Instruction
Current Version SSA-9303-Notice_of_Appointment-Please_Call_Reviewer[1].doc Current SSA-9303 IC Document
Current Version SSA-9304_Checklist_of_Required_Information[1].doc Current SSA-9304 IC Document

Information Collection (IC) Details

IC Title:	SSA-9303	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 418.(b)(5)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-9303	Notice of Appointment-Please Call Reviewer	Revised SSA-9303 Notice of Appointment - Please Call Reviewer.pdf		No		Paper Only
Instruction			Revised SSA-9304 Checklist of Required Information.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: 350	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	350	-150	500
Annual IC Time Burden (Hours)	88	-37	125
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-9303	Current Version SSA-9303-Notice_of_Appointment-Please_Call_Reviewer[1].doc	11/21/2011
Current SSA-9304	Current Version SSA-9304_Checklist_of_Required_Information[1].doc	11/21/2011

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