Personal Interview (SSA Field Office)

Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0784 can be found here:

Documents and Forms

Document Name Document Type
IRMAA Online Screens - 0960-0784.pdf Other-Intranet Screens
Revised PA and PRA Statements - SSA-44.pdf Other-Revised Privacy Act and PRA St

Information Collection (IC) Details

IC Title:	Personal Interview (SSA Field Office)	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 418.1265 20 CFR 418.2255 20 CFR 418.2265 20 CFR 418.1255 20 CFR 418.2205 20 CFR 418.1205

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Intranet Screens			IRMAA Online Screens - 0960-0784.pdf		Yes	Yes	Fillable Fileable Signable
Other-Revised Privacy Act and PRA Statements			Revised PA and PRA Statements - SSA-44.pdf		Yes	Yes	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 140,378	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	140,378	-6,622	147,000
Annual IC Time Burden (Hours)	70,189	-3,311	73,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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