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

Documents and Forms

Document Name Document Type
MAPS screens.docx Other-Intranet Screens

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			MAPS screens.docx		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: 5,291	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,291	-4,400	9,691
Annual IC Time Burden (Hours)	4,409	2,794	1,615
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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