Application for Help with Medicare Prescription Drug Plan Costs (Paper Form)

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⚠️ Notice: This information collection may be referencing outdated material.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
Form SSA-1020 Application for Help with Medicare Prescription Drug Plan Costs (Paper Form) Form and Instruction
Revised PA Statement.pdf Other-Revised PA Statement
SSA-1020 Application for Help with Medicare Prescription Drug Pla SSA-1020B-OCR-SM - Revised.pdf Form and Instruction
SSA-1020B-OCR-SM - Current.pdf SSA-1020 - Current IC Document

Information Collection (IC) Details

IC Title:	Application for Help with Medicare Prescription Drug Plan Costs (Paper Form)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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
Form and Instruction	SSA-1020	Application for Help with Medicare Prescription Drug Plan Costs	SSA-1020B-OCR-SM - Revised.pdf		No		Paper Only
Other-Revised PA Statement			Revised PA Statement.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 531,715	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	531,715	531,715
Annual IC Time Burden (Hours)	265,858	265,858
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-1020 - Current	SSA-1020B-OCR-SM - Current.pdf	12/18/2017

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