Paper Form SSA-44 (mailed or fillable PDF)

Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event

Documents and Forms

Document Name Document Type
0784 Privacy Act Statement (revised).docx Other-0784 Privacy Act Statement (re
0784 PRA (revised).pdf Other-0784 PRA Statement
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	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
Other-0784 Privacy Act Statement (revised)			0784 Privacy Act Statement (revised).docx	Yes	No	Printable Only
Other-0784 PRA Statement			0784 PRA (revised).pdf	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 76,645	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	76,645	16,483	60,162
Annual IC Time Burden (Hours)	57,484	12,362	45,122
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-44 - Current	SSA-44 (current).pdf	10/01/2020

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