SSA-1026-OCR-SCR Statement for Continuing Eligibility for Extra Help with

Social Security Administration
Reporting A Change That May Affect
Your Extra Help

Because of the report you made to us, we must review your eligibility for extra help with
Medicare Prescription Drug plan costs. We will check to be sure that you are still eligible and
that your extra help, also known as the subsidy, is correct. We want to make this review as
simple as possible for you, so you will not need to visit the office.
What We Will Do To Review Your Case
As part of the review, we will look at current information in our records. Your continued
eligibility is determined by the amount of your income, resources and household size. If you
have a spouse and you are living together, your total income and resources count.
What You Need To Do For This Review
• Please complete the enclosed form; do not use the form on the Internet website.
• Refer to the Income and Resources Summary on the back of this letter when completing
the form.
• Sign and return the form in the enclosed envelope within 90 days.
If You Do Not Return This Form
If you do not return this form within 90 days, your help with Medicare Prescription Drug
plan costs will be terminated. If you are waiting for information from another agency or need
assistance, you may call Social Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778).
If you do need assistance, we can give you an additional 30 days to return the form to us.

Regional Commissioner
Enclosures

Form

SSA-1026-OCR-SM-SCE (08-2007)

Social Security Administration
Income and Resources Summary
Name
Spouse Name

XXX-XX-9999
XXX-XX-9999

Refer to these figures when completing the enclosed form (SSA-1026):
Resources (see question 5)

Value

Bank accounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Stocks, bonds or other investments . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cash value of life insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Value of real estate other than your home . . . . . . . . . . . . . . . . . . . . . . . .
Household Size (see question 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Help with Household Expenses (see question 8)

Monthly Amount

Help With Household Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Income Not From Work (see question 9)

Monthly Amount

Social Security benefits (before deductions) . . . . . . . . . . . . . . . . . . . . . .
Railroad Retirement benefits (before deductions) . . . . . . . . . . . . . . . . . .
Veteran’s benefits (before deductions) . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other pensions or annuities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Earned Income (see question 10)

Annual Amount

Wages (before deductions)
Yours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Your spouse’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Net earnings from self-employment
Yours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Your spouse’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Net loss from self-employment
Yours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Your spouse’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Disability Or Blind Work Expenses (see question 11)
Disability work expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Blind work expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
KEEP THIS PAGE FOR YOUR RECORDS
Form

SSA-1026-OCR-SM-SCE (08-2007)

Monthly Amount

Statement for Continuing Eligibility
for Extra Help with Medicare
Prescription Drug Plan Costs

Please go to the next page
Form

SSA-1026-OCR-SM-SCE (08-2007)

Instructions for Completing the Statement
for Continuing Eligibility for Extra Help
with Medicare Prescription Drug Plan Costs
To Provide Extra Help in Paying for Your Drug Expenses
How To Complete This Form
• Refer to the Income and Resources Summary on the back of the enclosed letter
when completing this form;
• Use BLACK INK or a #2 pencil;
• Keep your numbers, Xs and letters inside the boxes; use only CAPITAL letters;
• Do not use dollar signs when entering money amounts. The dollar sign is
preprinted; and
• Cents can be rounded to the nearest whole dollar.
EXAMPLE

EXAMPLE
Use capital
letters when
entering answers

Put an X in the box. DO NOT fill
in or use check marks in boxes.

A B C D

X
CORRECT

INCORRECT

If You Are Assisting Someone Else With This Form
Answer the questions as if that person were completing the form. You must know that person’s
Social Security number and financial information. Also, complete Section B on page 6.

Completing Your Form
Please use the enclosed pre-addressed stamped envelope to return your completed and signed
form to:
Social Security Administration
Wilkes-Barre Data Operations Center
P.O. Box 1080
Wilkes-Barre, PA 18767
The Income and Resources Summary sheet on the back of the enclosed letter will assist you
in completing this form. Do not include the Income and Resources Summary sheet or any
attachments when you return the form in the enclosed postage-paid envelope. If we need
more information, such as statements from financial institutions, we will contact you.

If You Have Questions Or Need Help Completing This Form
You can call us toll-free at 1-800-772-1213, or if you are deaf or hard of hearing, you may
call our TTY number, 1-800-325-0778.
Form

SSA-1026-OCR-SM-SCE (08-2007)

Page 1

Form Approved
OMB No. 0960-0723

FOR OFFICIAL USE ONLY

Statement for Continuing Eligibility for Extra Help
with Medicare Prescription Drug Plan Costs
THIS DOES NOT ENROLL YOU IN THE
MEDICARE PRESCRIPTION DRUG PROGRAM.

State
Code:

WBDOC
Exception:

1. Name (Print each letter in a separate box.)

FIRST NAME

MI

LAST NAME
SOCIAL SECURITY NUMBER

SUFFIX (Jr., Sr., etc.)
DATE OF BIRTH
(MM - DD - YYYY)

MEDICARE CLAIM NUMBER
(This number is printed on your Medicare card)

EXAMPLE
For January- September
put a zero (0) in the first
box. May 20, 1935
should read:

0 5 2 0 1 9 3 5
M M D D Y Y Y Y

2. Spouse’s Name (if you are married and living together)
FIRST NAME

MI

LAST NAME

SPOUSE’S SOCIAL SECURITY NUMBER

SUFFIX (Jr., Sr., etc.)

SPOUSE’S DATE OF BIRTH
(MM - DD - YYYY)

SPOUSE’S MEDICARE CLAIM NUMBER
3. If your marital status has not changed or you already reported the change to us, go to question 4.
If your marital status has changed and you did not report it to us, what is your current marital status?
Married (living together)
Divorced/Widowed/Separated/Annulled
4. If all of the information on the Income and Resources Summary is correct, place an X in the red box
and go to question 12 on page 5, sign and return this form.
If any of the information on the Income and Resources Summary is incorrect, continue to question 5.
Form

SSA-1026-OCR-SM-SCE (08-2007)

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5. We need to know about resources that you, your spouse (if married and living together) or both of
you have.
Instructions: Please look at the information we have about your resources on the Income and
Resources Summary on the back of the enclosed letter.
If the information has not changed, place an X in the
red box and go to question 6.
If the information has changed, fill in the new amount in the boxes below.
Type of Resource
The Correct Amount Is
Bank accounts (checking, savings
and certificates of deposit)
Stocks, bonds, savings bonds, mutual
funds, Individual Retirement Accounts
or other similar investments
Cash

Cash value of life insurance

Value of real estate other than your home

6. Do you expect to use money from any sources listed in question 5 to pay for funeral or burial
expenses for yourself (or your spouse,
YOU:
YES
NO
if married and living together)?
SPOUSE (if living together):

YES

NO

7. Your household size may affect the amount of help you can get. We need to know how many
relatives live with you and your spouse (if married and living together) for whom you or your
spouse provide at least one-half of their financial support. Relatives may include anyone related
to you by blood, marriage or adoption.
Instructions: Please look at the information we have about your household size on the Income and
Resources Summary on the back of the enclosed letter.
If the information has not changed, place an X in
the red box and go to question 8.
If the number of these relatives has changed, how many relatives live with you now?
Place an X in only one box below. If you live alone or only with your spouse check NONE.

NONE
Form

1

2

3

4

SSA-1026-OCR-SM-SCE (08-2007)

5
Page 3

6

7

8

9 or more

8. We need to know about help with household expenses that you, your spouse (if married and living
together) or both of you receive. Help with household expenses is when anyone provides
or helps you pay for any of the following: food, mortgage, rent, heating fuel or gas, electricity, water
and property taxes. (It does not include food stamps, house repairs, help from a housing agency,
an energy assistance program, Meals on Wheels or help with medical treatment and drugs.)
Instructions: Please look at the information we have about help you received with household
expenses on the Income and Resources Summary on the back of the enclosed letter.
If the amount you receive is the same as the amount on the Summary, place an X in the red box.

If the amount you receive is more than the amount on the Summary, place an X in the red box.

If the amount you receive is less than the amount on the Summary, place an X in the red box.
9. We need to know about income not from work that you, your spouse (if married and living
together) or both of you have from any of the sources listed below.
Instructions: Please look at the information we have about your income not from work on the
Income and Resources Summary on the back of the enclosed letter.
If the information has not changed, place an X in the red box and go to question 10.
If the information has changed, fill in the new amount in the boxes below.
The Correct Monthly Amount Is
Social Security benefits (before deductions)

Railroad Retirement benefits (before deductions)

Veteran’s benefits (before deductions)

Other pensions or annuities (Do not include money
you receive from any item listed in question 5.)
Other income

Form

SSA-1026-OCR-SM-SCE (08-2007)

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10. We need to know about annual earned income from work that you, your spouse (if married and
living together) or both of you have.
Instructions: Please look at the information we have about your earned income on the Income and
Resources Summary on the back of the enclosed letter.
If the information has not changed, place an X in the red box and go to question 11.

If the information has changed, fill in the new amount in the boxes below.
Type of Earned Income

The Correct Annual Amount Is

Wages

You
Your Spouse

Net earnings from self-employment

You
Your Spouse

Net loss from self-employment

You
Your Spouse

11. Do you, your spouse (if married and living together) or both have to pay for things that enable
you to work (also known as disability or blind work expenses)? We will count only a part of
your earnings toward the income limit if you work and receive Social Security benefits based on
a disability or blindness and you have work-related expenses for which you are not reimbursed.
Examples of such expenses are: the costs of medical treatment and drugs for AIDS, cancer,
depression or epilepsy; a wheelchair; personal attendant services; vehicle modifications, driver
assistance or other special work-related transportation needs; work-related assistive technology;
guide dog expenses; sensory and visual aids; and Braille translations.

YOU:

YES

NO

SPOUSE (if living together):

YES

NO

12. If you or your spouse (if married and living together) work and plan to stop working, enter month
and year. Otherwise sign the form on page 6 and return it to us.
EXAMPLE
For January – September,
put a zero (0) in the
first box. May 2006
should read:

20

YOU:

0 5

2 0 0 6

M M

Y Y Y Y

M M

20

YOUR SPOUSE:
M M

Form

SSA-1026-OCR-SM-SCE (08-2007)

Page 5

Y Y Y Y

Y Y Y Y

Signatures
IMPORTANT INFORMATION - PLEASE READ CAREFULLY
I/We understand that the Social Security Administration (SSA) will check my/our statements and
compare its records with records from Federal, State, and local government agencies, including the
Internal Revenue Service (IRS) to make sure the determination is correct.
By submitting this application, I am/we are authorizing SSA to obtain and disclose information related to
my/our income, resources, and assets, foreign and domestic, consistent with applicable privacy laws. This
information may include, but is not limited to, information about my/our wages, account balances,
investments, insurance policies, benefits, and pensions.
I/We declare under penalty of perjury that I/we have examined all the information on this form and it is
true and correct to the best of my/our knowledge.
Please complete Section A. If you cannot sign, a representative may sign for you. If someone
assisted you, complete Section B as well.

Section A
Your Signature:

Date:

Spouse’s Signature:

Date:

Phone Number:

Your Mailing Address:

Apt. #:

City:

State:

Zip Code:

If you changed your mailing address within the last three months, place an X in the red box:
If you would prefer that we contact someone else if we have additional questions, please provide the
person’s name and a daytime phone number.
Print First Name:
Print Last Name:
Phone Number:

Section B
If you are assisting someone else, place an X in the red box that describes who you are and provide your
daytime phone number and address.
Family Member
Friend
Print First Name:

Attorney
Agency

Other Advocate
Social Worker
Print Last Name:

Other
Specify: _______________
______________________
Phone Number:

Address:

Apt. #:
State:

City:
Form

SSA-1026-OCR-SM-SCE (08-2007)

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Zip Code:

Privacy Act / Paperwork Reduction Notice
Section 1860 D-14 of the Social Security Act authorizes the collection of information
requested on this form. The information you provide will be used to enable the Social
Security Administration (SSA) to determine if you continue to be eligible for help
paying your share of the cost of a Medicare Prescription Drug Plan. You do not have
to give us the information requested. However, failure to provide all or part of the
information could prevent an accurate and timely decision on your continuing eligibility
for benefits and could result in the loss of your extra help with Medicare Prescription
Drug plan costs. We may provide information collected on this form to another Federal,
State, or local government agency to assist us in determining your eligibility for the
subsidy or if a Federal law requires the release of the information. We also may need
to share the information with other SSA programs if SSA needs to determine your
eligibility in those programs.
We may also use the information you give us when we match records by computer.
Matching programs compare our records with those of other Federal, State, or local
government agencies. Many agencies may use matching programs to find or prove that
a person qualifies for benefits paid by the Federal government. The law allows us to
do this even if you do not agree to it. Explanations about these and other reasons why
information you provide us may be used or given out are available in Social Security
offices. If you want to learn more about this, contact any Social Security office.
Paperwork Reduction Act Statement — This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork
Reduction Act of 1995. You do not need to answer these questions unless we display a
valid Office of Management and Budget control number. We estimate that it will take
about 20 minutes to read the instructions, gather the facts, and answer the questions.
You may send comments on our time estimate above to: SSA, 6401 Security Blvd.,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to
this address, not the completed form.
SEND THE COMPLETED FORM TO US AT THE ADDRESS SHOWN ON THE
ENCLOSED PRE-ADDRESSED, POSTAGE-PAID ENVELOPE:
Social Security Administration
Wilkes-Barre Data Operations Center
P.O. Box 1080
Wilkes-Barre, PA 18767

Form

SSA-1026-OCR-SM-SCE (08-2007)

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