SSA-1026-SCE - Reporting a Change That May Affect Your Extra Help

Redetermination of Eligibility for Help with Medicare Prescription Drug Plan Costs

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0723 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-1026-SCE SSA-1026-SCE - Reporting a Change That May Affect Your Extra Help Form and Instruction
Revised PA Statement.pdf Other-Revised PA Statement
0960-0723 Revised MAPS MEDQ.pdf Other-MAPS screens
SSA-1026-SCE SSA - Reporting a Change That May Affect Your Extra Help SSA-1026-SCE - Revised.pdf Form and Instruction
0960-0723 Current Screenshots MAPS MEDQ.pdf MAPS MEDQ current screens IC Document

Information Collection (IC) Details

IC Title:	SSA-1026-SCE - Reporting a Change That May Affect Your Extra Help	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 418.3125

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-1026-SCE	SSA - Reporting a Change That May Affect Your Extra Help	SSA-1026-SCE - Revised.pdf	No		Fillable Printable
Other-Revised PA Statement			Revised PA Statement.pdf	No		Fillable Printable
Other-MAPS screens			0960-0723 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: 4,267	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	4,267	4,267
Annual IC Time Burden (Hours)	1,280	1,280
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
MAPS MEDQ current screens	0960-0723 Current Screenshots MAPS MEDQ.pdf	01/16/2019

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