Document Headings

                    Document headings vary by document type but may contain                    the following:                  
                -                       the agency or agencies that issued and signed a document                    
                -                       the number of the CFR title and the number of each part                      the document amends, proposes to amend, or is directly                      related to                    
                -                       the agency docket number / agency internal file number                    
                -                       the RIN which identifies each regulatory action listed in                      the Unified Agenda of Federal Regulatory and Deregulatory                      Actions                    

                    See the                                          Document Drafting Handbook                                        for more details.                  

###### Social Security Administration

                    The Social Security Administration (SSA) publishes a list of information                           ( print page 67380)                        collection packages that will require clearance by the Office of Management and Budget (OMB) in compliance with Public Law 104-13 effective October 1, 1995, The Paperwork Reduction Act of 1995. The information collection packages that may be included in this notice are for new information collections.                 

SSA is soliciting comments on the accuracy of the agency's burden estimate; the need for the information; its practical utility; ways to enhance its quality, utility and clarity; and on ways to minimize burden on respondents, including the use of automated collection techniques or other forms of information technology. Written comments and recommendations regarding the information collection(s) should be submitted to the OMB Desk Officer and the SSA Reports Clearance Officer. 

(OMB), Office of Management and Budget, Attn: Desk Officer for SSA, Fax: 202-395-6974. 

                    (SSA), Social Security Administration, DCFAM, Attn: Reports Clearance Officer, Fax: 410-965-6400, E-mail:                     *OPLM.RCO@ssa.gov.*

The information collections listed below have been submitted to OMB for clearance. In order for your comments to be considered, you must send them by December 17, 2004. You can obtain a copy of the OMB clearance package by calling the SSA Reports Clearance Officer at 410-965-0454, or by writing to the e-mail address listed above. 

## 1. Application for Help With Medicare Prescription Drug Plan Costs—0960-NEW 

                    SSA published a notice in the                     **Federal Register**                     on September 30 (69 FR 58578) informing the public that OMB is reviewing form SSA-1020, the Application for Help with Medicare Prescription Drug Plan Costs. At the time this notice was published, SSA received public comments and withheld submission of the forms in order to evaluate these comments. As a result, SSA has revised form SSA-1020, submitted it to OMB for its review, and is republishing the Notice below. Comments must be received within 30 days of publication of this Notice in order to be considered.                 

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. 108-173; MMA) establishes a new Medicare Part D program for voluntary prescription drug coverage for premium, deductible and cost-sharing subsidies for certain low-income individuals. The MMA stipulates that subsidies must be available for individuals who are eligible for the program and who meet eligibility criteria for help with premium, deductible, and/or co-payment costs. Form SSA-1020, the Application for Help with Medicare Prescription Drug Plan Costs, collects information about an applicant's resources and is used by SSA to determine eligibility for this assistance. The respondents are individuals who are eligible for enrollment in the new program and are requesting assistance with the related costs. 

# Note:

                        Since publishing the 60-day                         **Federal Register**                         Notice (69 FR 45879), SSA has decided to conduct a pilot test of form SSA-1020 in March 2005. This test is intended to assist SSA in: (1) Determining how eligible individuals will respond to its Part D Subsidy application outreach (scheduled to begin in June 2005) and (2) testing its systems processing of the SSA-1020 application. SSA will use the information to make actual subsidy eligibility determinations. The Agency will conduct the test with approximately 2,000 beneficiaries potentially eligible for Part D cost-sharing subsidies by providing them with copies of form SSA-1020.                    

*Type of Request:*                     New information collection.                 

*Number of Respondents:*                     5,000,000.                 

*Frequency of Response:*                     1.                 

*Average Burden Per Response:*                     35 minutes.                 

*Estimated Annual Burden:*                     2,916,667 hours.                 

## 2. Appeal of Determination for Help With Medicare Prescription Drug Plan Costs—0960-NEW 

                    SSA published a notice in the                     **Federal Register**                     on September 30 (69 FR 58578) informing the public that OMB is reviewing form SSA-1021, Appeal of Determination for Help with Medicare Prescription Drug Plan Costs. At the time this notice was published, SSA received public comments and withheld submission of the form in order to evaluate the comments. As a result, SSA has revised form SSA-1021, submitted it to OMB for its review, and is republishing the Notice below. Comments must be received within 30 days of publication of this Notice in order to be considered.                 

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. 108-173; MMA) establishes a new Medicare Part D program for voluntary prescription drug coverage for premium, deductible, and cost-sharing subsidies for certain low-income individuals. The MMA stipulates that subsidies must be available for individuals who are eligible for the program and who meet eligibility criteria for help with premium, deductible, and/or co-payment costs. Form SSA-1021, the Appeal of Determination for Help with Medicare Prescription Drug Plan Costs, was developed to obtain information from individuals who appeal SSA's decisions regarding eligibility or continuing eligibility for a Medicare Part D subsidy. The respondents are applicants who are appealing SSA's eligibility or continuing eligibility decisions. 

*Type of Request:*                     New information collection.                 

*Number of Respondents:*                     75,000.                 

*Frequency of Response:*                     1.                 

*Average Burden Per Response:*                     10 minutes.                 

*Estimated Annual Burden:*                     12,500 hours.                 

Dated: November 12, 2004. 

Elizabeth A. Davidson, 

Reports Clearance Officer, Social Security Administration. 

[FR Doc. 04-25489 Filed 11-16-04; 8:45 am] 

BILLING CODE 4191-02-P