Paper Form SSA-44 (mailed or fillable PDF)

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⚠️ Notice: This information collection may be referencing outdated material.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
Form SSA-44 Paper Form SSA-44 (mailed or fillable PDF) Form and Instruction
SSA-44 Medicare Income-Related Monthly Adjustment Amount - Life SSA-44 - Revised.pdf Form and Instruction
SSA-44 - Current.pdf SSA-44 - Current IC Document

Information Collection (IC) Details

IC Title:	Paper Form SSA-44 (mailed or fillable PDF)	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 418.1255 20 CFR 418.1265 20 CFR 418.2265 20 CFR 418.2205 20 CFR 418.2255 20 CFR 418.1205

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 Income-Related Monthly Adjustment Amount - Life-Changing Event	SSA-44 - Revised.pdf		No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60,162	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	60,162	60,162
Annual IC Time Burden (Hours)	45,122	45,122
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-44 - Current	SSA-44 - Current.pdf	12/12/2018

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