Application for Extra Help With Medicare Prescription Drug Plan Costs (field office interview)

Application for Help with Medicare Prescription Drug Plan Costs

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0696 can be found here:

Documents and Forms

Document Name Document Type
SSA-1026 MAPS MEDQ - Revised Screenshots.docx Other-Screens for SSA field office i
SSA-1026 MAPS MEDQ - Current Screenshots.docx Current MAPS Screens IC Document

Information Collection (IC) Details

IC Title:	Application for Extra Help With Medicare Prescription Drug Plan Costs (field office interview)	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 418.3101

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screens for SSA field office interview			SSA-1026 MAPS MEDQ - Revised Screenshots.docx		No		Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 108,194	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	108,194	108,194
Annual IC Time Burden (Hours)	54,097	54,097
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current MAPS Screens	SSA-1026 MAPS MEDQ - Current Screenshots.docx	02/01/2019

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