Information Collection

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

IC 187636 under ICR 201109-0960-013 · OMB 0960-0696.

⚠️ Notice: This information collection may be referencing outdated material.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
field office screens.pdf Other-Screens for SSA field office i

Information Collection (IC) Details

View Information Collection (IC)

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			field office screens.pdf		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: 278,613	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	278,613	78,613	200,000
Annual IC Time Burden (Hours)	139,307	39,307	100,000
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.