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Federal forms, ICRs, and supporting documents

Information Collection Request

Application for Help with Medicare Prescription Drug Plan Costs

ICR 200411-0960-005 · OMB 0960-0696 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
9750 Application for Help with Medicare Prescription Drug Plan Costs Form Migrated
ICR Details
0960-0696 200411-0960-005
Historical Active
SSA
Application for Help with Medicare Prescription Drug Plan Costs
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 12/23/2004
Retrieve Notice of Action (NOA) 11/17/2004
Approved with substitution of Form SSA-1020-OCR-SM submitted to O MB 12/22/04.
  Inventory as of this Action Requested Previously Approved
12/31/2007 12/31/2007
5,000,000 0 0
2,916,667 0 0
0 0 0
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173; MMA) establishes a new Medicare Part D Program for voluntary prescription drug coverage for certain individuals. The MMA mandates that subsidies must be available to individuals who qualify for the program and who meet eligibility criteria for help with premium, deductible, and co-payment costs. Form SSA-1020 is used as an application for this subsidy. The respondents are applicants for the Medicare Part D Subsidy.
None
None
No
1
IC Title Form No. Form Name
Application for Help with Medicare Prescription Drug Plan Costs SSA-1020
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 5,000,000 0 0 5,000,000 0 0
Annual Time Burden (Hours) 2,916,667 0 0 2,916,667 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
11/17/2004