Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - MAPS Intranet 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⚠️ Notice: This information collection may be referencing outdated material.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
0960-0695 Revised MAPS MEDQ.pdf Other-Intranet Screens
0960-0695 Current Screenshots MAPS MEDQ.pdf MAPS MEDQ current screens IC Document

Information Collection (IC) Details

IC Title:	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - MAPS Intranet Version	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Intranet Screens			0960-0695 Revised MAPS MEDQ.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11,037	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	11,037	11,037
Annual IC Time Burden (Hours)	1,840	1,840
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
MAPS MEDQ current screens	0960-0695 Current Screenshots MAPS MEDQ.pdf	01/09/2019

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