Form SSA-1020 Application for Help with Medicare Prescription Drug Pla

Social Security Administration
Important Information

You may be eligible to get extra help paying for your prescription drugs.
The Medicare Prescription Drug program gives you a choice of prescription plans
that offer various types of coverage.
You may be able to get extra help to pay for the monthly premiums, annual
deductibles, and co-payments related to the Medicare Prescription Drug program.
But before we can help you, you must fill out the application, put it in the
enclosed envelope and mail it today. Or you may complete an online application
at www.socialsecurity.gov. We will review your application and send you a letter
to let you know if you qualify for extra help. To use the extra help, you must
enroll in a Medicare Prescription Drug plan.
If you need help completing the application, call Social Security at 1-800-772-1213
(TTY 1-800-325-0778). You can find more information at www.socialsecurity.gov.
If you need information about Medicare Prescription Drug plans or how to enroll in
a plan, call 1-800-MEDICARE (TTY 1-877-486-2048) or visit www.medicare.gov.
Mail your application today. We will give you a decision about whether you qualify
for the extra help.

Michael J. Astrue
Commissioner

Form

SSA-1020B-OCR-SM (12-2007) Destroy prior editions

General Instructions for Completing the
Application for Help with Medicare
Prescription Drug Plan Costs
Do you or the person you are helping apply have Medicare and Supplemental Security
Income (SSI) or Medicare and Medicaid?
If the answer is YES, do not complete this application because you automatically will get
the extra help.
Does your state Medicaid program pay your Medicare premiums because you belong to a
Medicare Savings Program?
If the answer is YES, contact your state Medicaid office for more information. You could
get the extra help automatically and may not need to complete this application.

How To Complete This Application
• Use BLACK INK only;
•
•
•
•

Keep your numbers, letters and Xs inside the boxes; use only capital letters;
Do not add any handwritten comments on the application;
Do not use dollar signs when entering money amounts; and
Cents can be rounded to the nearest whole dollar.
EXAMPLE
Place an X in the box. DO NOT fill
in or use check marks in boxes.

X
CORRECT

EXAMPLE
Use capital
letters when
entering answers

INCORRECT

A B C D

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

Completing Your Application
You may complete the online application at www.socialsecurity.gov or use the enclosed
pre-addressed stamped envelope to return your completed and signed application to:
Social Security Administration
Wilkes-Barre Data Operations Center
P.O. Box 1020
Wilkes-Barre, PA 18767-9910
Return this application package in the enclosed envelope. Do not include anything else in the
envelope. If we need more information, we will contact you.

If You Have Questions Or Need Help Completing This Application
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-1020B-OCR-SM (12-2007)

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Form Approved
OMB No. 0960-0696

Application for Help with Medicare
Prescription Drug Plan Costs

FOR OFFICIAL USE ONLY

THIS DOES NOT ENROLL YOU IN A
MEDICARE PRESCRIPTION DRUG PLAN.

State code:

WBDOC
Exception:

1. Applicant’s Name: Print name as it appears on your Social Security card. Use one box for each letter.
FIRST NAME

MI

LAST NAME

SUFFIX (Jr., Sr., etc.)

Applicant’s Social Security Number

Applicant’s Date of Birth
(MM-DD-YYYY)

2. If you are married and living with your spouse, please provide the following information as it appears
on your spouse’s Social Security card. If you are not currently married or do not live with your spouse,
skip to question 3 and do not include any information about your spouse on this application.
FIRST NAME

MI

LAST NAME

SUFFIX (Jr., Sr., etc.)

Spouse’s Social Security Number
If your spouse has Medicare, does he or
she also wish to apply for the extra help?

Spouse’s Date of Birth
(MM-DD-YYYY)
YES

NO

3. If you are married and living with your spouse, do you have savings, investments or real estate
worth more than $23,970? If not married or you don’t live with your spouse, do you have savings,
investments or real estate worth more than $11,990? DO NOT include the home you live in,
vehicles, personal possessions, burial plots or irrevocable burial contracts.
YES

If you place an in the YES box, STOP. You are not eligible for the extra help and
you do not need to return this application to us. If you need a letter stating you are not
eligible, sign the application on page 6 and return it to us.

NO or NOT SURE

Form

If you place an in the NO or NOT SURE box, complete the rest
of this application and return it to us.

SSA-1020B-OCR-SM (12-2007)

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If you placed an in the NO or NOT SURE box in question 3, answer all of the
following questions. If you are married and living with your spouse, you must
answer all of the questions for both of you.
4. Please enter the money amounts of all bank accounts, investments or cash that either you, your
spouse, if married and living together, or both of you own in the boxes below. Include items that
either of you own with another person. Include only the dollar figures, not the account number.
If you or your spouse do not own an item listed, either separately, jointly or with another person,
place an in the NONE box.
• Combined total of all bank accounts
(checking, savings and certificates
of deposit)

NONE

• Combined total of all stocks, bonds,
savings bonds, mutual funds,
Individual Retirement Accounts or
other similar investments

NONE

• Any other cash at home or
anywhere else

NONE

5. Do you own life insurance policies with a total face value of more than $1,500? Answer for you
and your spouse if your spouse lives with you.
If you answer NO for both you and your spouse, go to question 6.
YOU:
YES
NO
SPOUSE:

YES

NO

If you answered YES for either of you, how much money would you get if you turned in your
policies for cash right now? Enter the amount. If you answered YES for both you and your spouse,
enter the combined amount. This is not the face value of your policies. You may need to call your
insurance company to help answer this question.

6. Will some money from the sources listed in questions 4 and 5 be used to pay for funeral or burial
expenses? If YES, skip to question 7.
If NO, place an in the NO box, then go to question 7.
YOU:
NO
SPOUSE:

NO

7. Other than your home and the property on which it is located, do you or your spouse, if married
and living together, own any real estate? Examples of other real estate are summer homes, rental
properties or undeveloped land you own.
YES
NO
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SSA-1020B-OCR-SM (12-2007)

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8. Not counting your spouse if you are married, how many other relatives live in your household and
receive at least one-half of their financial support from you or your spouse? We count relatives
related to you by blood, marriage or adoption.

Place an in only one box. Do not include yourself or your spouse in the number you enter. If
your household consists only of you or you and your spouse, place an in the NONE box.

NONE

1

2

3

4

5

6

7

8

9 or more

9. If you or your spouse, if married and living together, receive income from any of the sources listed
below, please enter the total amount you receive each month. If the amount changes from month
to month or you do not receive it every month, enter the average monthly income for the past
year for each type in the appropriate boxes. Do not list wages and self-employment, interest income,
public assistance, medical reimbursements or foster care payments here. If you or your spouse do not
receive income from a source listed below, place an in the NONE box for that source.
Monthly Benefit
• Social Security benefits
NONE
before deductions
• Railroad Retirement benefits
before deductions

NONE

• Veterans benefits before deductions

NONE

• Other pensions or annuities before
deductions. Do not include money
you receive from any item you included
in question 4.

NONE

• Other income not listed above, including
alimony, net rental income, workers’
compensation, etc. (Specify):
_______________________________

NONE

10. Have any of the amounts you included in question 9 decreased during the last two years?
YES
NO
11. Do you count on anyone to help pay for any of the following household expenses — food,
mortgage, rent, heating fuel or gas, electricity, water and property taxes? Do NOT include food
stamps, house repairs, help from a housing agency, an energy assistance program, Meals on
Wheels, contributions from food banks, soup kitchens or help with medical treatment and drugs.
Do not include small amounts of money given occasionally or unexpectedly.
YES
NO
If you place an in the YES box, enter the monthly amount
or, if the amount changes from month to month, enter the
average monthly amount for the past year.
Form

SSA-1020B-OCR-SM (12-2007)

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If you have worked in the last two years, you need to answer questions 12-16. If
you are married and living with your spouse and either one of you has worked
in the last two years, you need to answer questions 12-16. Otherwise, sign the
application on page 6 and return it to us.
12. What do you expect to earn in wages before taxes and deductions this calendar year?
YOU:

NONE

SPOUSE:

NONE

13. What do you expect your net earnings from self-employment to be this calendar year?
Place an in the NONE box if you are not self-employed and go to question 14.

YOU:

NONE

SPOUSE:
Place an in the box(es) if you
or your spouse expect a net loss.

NONE
YOU:

SPOUSE:

14. Have the amounts you included in questions 12 or 13 decreased in the last two years?
YES

NO

15. If you or your spouse, stopped working in 2007 or 2008, or plan to stop working in 2008 or 2009,
enter the month and year.
EXAMPLE
For January – September,
place a zero (0) in the
first box. May 2007
should read:

YOU:

0 5

2 0 0 7

M M Y Y Y Y

SPOUSE:

2 0
M M

Y Y Y Y

2 0
M M

Y Y Y Y

If you are younger than age 65, answer question 16. If you are married and
living with your spouse and either one of you is younger than age 65, answer
question 16. Otherwise, sign the application on page 6 and return it to us.
16. Do you or your spouse have to pay for things that enable you to work? 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 cost 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:
Form

YES

NO

SSA-1020B-OCR-SM (12-2007)

SPOUSE:
Page 5

YES

NO

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:

Phone Number:

Date:

Spouse’s Signature:

Date:

Your Mailing Address:

Apt. #:

City:

State:

If you changed your mailing address within the last three months, place an

Zip Code:
here:

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 someone assisted you, place an
information requested below.
Family Member
Friend
Print First Name:

in the box that describes that person and provide the rest of the

Attorney
Agency

Other Advocate
Social Worker
Print Last Name:

Other
Specify:________________
______________________
Phone Number:

Address:

Apt. #:

City:
Form

State:
SSA-1020B-OCR-SM (12-2007)

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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 to determine if you are 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, if you do not provide the information, we will be unable to make
an accurate and timely decision on your application. 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 extra help or if a Federal law requires the release
of information.
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 35 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 ENVELOPE:
Social Security Administration
Wilkes-Barre Data Operations Center
P.O. Box 1020
Wilkes-Barre, PA 18767-9910

Form

SSA-1020B-OCR-SM (12-2007)

Page 7