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

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⚠️ Notice: This information collection may be referencing outdated material.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 www.ssa.gov Instruction
SSA-1021 - Revised PA Statement.pdf www.ssa.gov Other-Revised Privacy Act Statement
SSA-1021 Appeal of Determination for Help with Medicare Prescript SSA-1021 - Revised Version.pdf www.ssa.gov Form
SSA-1021 - Current Version.pdf Current SSA-1021 IC Document
SSA-1021-INST - Current Version.pdf Current SSA-1021-INST IC Document

Information Collection (IC) Details

IC Title:	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - Paper Version	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
Instruction			096-0695 APPEAL SCRNS.doc	www.ssa.gov	Yes	No	Printable Only
Form	SSA-1021	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs	SSA-1021 - Revised Version.pdf	www.ssa.gov	Yes	No	Fillable Printable
Other-Revised Privacy Act Statement			SSA-1021 - Revised PA Statement.pdf	www.ssa.gov	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,283	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	3,283	-13,055	16,338
Annual IC Time Burden (Hours)	547	-2,176	2,723
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-1021	SSA-1021 - Current Version.pdf	06/13/2017
Current SSA-1021-INST	SSA-1021-INST - Current Version.pdf	06/13/2017

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