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pdfWelcome
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
The OMB control number for this application is 0960-0696; expiration date 5/31/2008.
Welcome!
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. However, you must be enrolled in a Medicare Prescription Drug plan to get this extra
help.
What Is This Application?
It is an application for extra help with the prescription drug costs. It does not enroll you in a Medicare prescription drug
plan. You will have to enroll directly with an approved Medicare prescription drug provider for coverage. 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.
Who Should Complete This Application For Extra Help With Medicare Prescription Drug Plan Costs?
EXCEPTION: Even if you meet these conditions, DO NOT complete this application if you have Medicare and
Supplemental Security Income (SSI) or Medicare and Medicaid because you automatically will get the extra help.
If your state pays your Medicare premiums because you belong to a Medicare Savings Program, you should contact
your state Medicaid office for more information. You could get the extra help automatically and may not need to
complete this application.
How Can You Get The Extra Help?
To get extra help with prescription drug costs, you must complete and submit this application. We will review
your application and send you a letter to let you know if you qualify for extra help.
If you need help completing this application, call Social Security toll-free at 1-800-772-1213. If you are deaf or hard
of hearing, call our toll-free TTY number at 1-800-325-0778.
You should complete this application for extra help on the Internet if:
What Do You Want To Do?
●
You have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance); and
●
You live in one of the 50 states or the District of Columbia; and
●
Your combined savings, investments, and real estate are not worth more than $23,410, if you are married and living with
your spouse, or $11,710 if you are not currently married or not living with your spouse. (DO NOT include the home you
live in, vehicles, personal possessions, burial plots or irrevocable burial contracts.) If you have more than those
amounts, you may not qualify for the extra help. However, you can still enroll in an approved Medicare prescription drug
plan for coverage.
Apply Now
Return To An Existing Application
Not Sure If You Should Use This?
Find Out If You Qualify
Related Links
Information About This Application:
What You Will Need
Special Instructions For Blind Users
Other Ways To Apply
How The Online Application Works
Medicare Information:
About The Prescription Drug Program
Official U.S. Government Medicare Site
Centers For Medicare & Medicaid
Services
Legal And Official Information:
Internet Security Policy
Paperwork Reduction Act
Website Policies & Other Important
Information
Privacy Act Statement
Social Security is allowed to collect the facts on this application under Section 205 of the Social Security Act. We need this information
to efficiently process your Internet application. Giving us these facts is voluntary. However, without them we may not be able to process
your application online. Social Security may provide information collected on this application 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
also may need to share the information with other Social Security programs if Social Security 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 read
more information on this subject, read The Collection and Use of Information From Your Application - Privacy Act Statement.
Social Security has access to the information you provide on this application and is authorized to keep information on applications that
were partially completed. This is for purposes of helping you complete the application process. If you have decided you want to continue,
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/ee001.html (1 of 2) [9/10/2007 7:29:41 AM]
Welcome
you can apply now or, if you are undecided, you may file at a later time.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/ee001.html (2 of 2) [9/10/2007 7:29:41 AM]
Welcome
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
The OMB control number for this application is 0960-0696; expiration date 5/31/2008.
Welcome!
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. However, you must be enrolled in a Medicare Prescription Drug plan to get this extra
help.
What Is This Application?
It is an application for extra help with the prescription drug costs. It does not enroll you in a Medicare prescription drug
plan. You will have to enroll directly with an approved Medicare prescription drug provider for coverage. 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.
Who Should Complete This Application For Extra Help With Medicare Prescription Drug Plan Costs?
EXCEPTION: Even if you meet these conditions, DO NOT complete this application if you have Medicare and
Supplemental Security Income (SSI) or Medicare and Medicaid because you automatically will get the extra help.
If your state pays your Medicare premiums because you belong to a Medicare Savings Program, you should contact
your state Medicaid office for more information. You could get the extra help automatically and may not need to
complete this application.
How Can You Get The Extra Help?
To get extra help with prescription drug costs, you must complete and submit this application. We will review
your application and send you a letter to let you know if you qualify for extra help.
If you need help completing this application, call Social Security toll-free at 1-800-772-1213. If you are deaf or hard
of hearing, call our toll-free TTY number at 1-800-325-0778.
You should complete this application for extra help on the Internet if:
Apply Now
●
You have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance); and
●
You live in one of the 50 states or the District of Columbia; and
●
Your combined savings, investments, and real estate are not worth more than $23,410, if you are married and living
with your spouse, or $11,710 if you are not married or not living with your spouse. (DO NOT include the home you live
in, vehicles, personal possessions, burial plots or irrevocable burial contracts.) If you have more than those amounts,
you may not qualify for the extra help. However, you can still enroll in an approved Medicare prescription drug plan for
coverage.
Related Links
Information About This Application:
What You Will Need
Special Instructions For Blind Users
Other Ways To Apply
How The Online Application Works
Medicare Information:
About The Prescription Drug Program
Official U.S. Government Medicare Site
Centers For Medicare & Medicaid
Services
Legal And Official Information:
Internet Security Policy
Paperwork Reduction Act
Website Policies & Other Important
Information
Privacy Act Statement
Social Security is allowed to collect the facts on this application under Section 205 of the Social Security Act. We need this information
to efficiently process your Internet application. Giving us these facts is voluntary. However, without them we may not be able to process
your application online. Social Security may provide information collected on this application 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
also may need to share the information with other Social Security programs if Social Security 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 read
more information on this subject, read The Collection and Use of Information From Your Application - Privacy Act Statement.
Social Security has access to the information you provide on this application and is authorized to keep information on applications that
were partially completed. This is for purposes of helping you complete the application process. If you have decided you want to continue,
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/ee001fe.html (1 of 2) [9/10/2007 7:29:43 AM]
Welcome
you can apply now or, if you are undecided, you may file at a later time.
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Should You Use This Application?
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Should You Use This Application?
Not everyone will be able to use the online Application For Help With Medicare Prescription Drug Plan Costs.
You must answer a few questions to help determine if you should use this Internet form. Any time there is a
link at the end of a question that says "More Info," you can follow that link to get help with that question.
The OMB control number for this application is 0960-0696; expiration date 5/31/2008.
Are you assisting someone (other than your spouse who lives with you) with this application? More
Info
If you are helping another person fill out this application, answer the following questions as if you were the
person.
No
Yes
Did you (or your spouse, if married and living together) get an application in the mail from us?
More Info
No
Yes
Do you (or your spouse, if married and living together) have Medicare?
More Info
No
Yes
Are you (or your spouse, if married and living together) 64 years and 9 months old or older?
More Info
No
Yes
Have you (or your spouse, if married and living together) received:
More Info
No
Yes
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Should You Use This Application?
●
Social Security disability benefits for 24 months;
●
Disability benefits based on Lou Gehrig's disease (ALS); or
●
Renal dialysis treatments or a kidney transplant?
In which state do you (and your spouse, if married and living together) live?
More Info
Select One
What is your marital status? More
Info
Select One
Do you have combined savings, investments and real estate worth more than: More Info
●
$23,410 if you are married and living with your spouse; or
●
$11,710 if you are not married or not living with your spouse?
Include the things you own by yourself, with your spouse or with someone else. DO NOT include the home
you live in, vehicles, personal possessions, burial plots or irrevocable burial contracts.
No
sure
Yes
Not
Previous
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Continue
Welcome Back
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Welcome Back!
Please enter the applicant's Social Security and Reentry Numbers to return to the Application For
Help With Medicare Prescription Drug Plan Costs already started. If you do not have the applicant's
Reentry Number, you will not be able to continue with the application already begun. You may start
a new online application up to three times. If you have a problem using this online application, call
our toll-free number at 1-800-772-1213 (TTY 1-800-325-0778) and they will help you. However,
Social Security cannot access the applicant's Reentry Number.
Applicant's Social Security
Number:
Reentry
Number:
Previous
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Continue
Sign Out
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Sign Out
If you want to, you can stop now. Later, you can come back to where you left off and continue with
this application. You can review the parts you already completed and add or change information.
To Come Back To This Application:
1. Go to this website: www.socialsecurity.gov/prescriptionhelp; and
2. Type in the Applicant's Social Security and Reentry Numbers shown below.
Applicant's Social Security Number:
743991047
Reentry Number: 65571762
Print or save this page so you will have a copy of your Reentry Number. To print this page, please
use the Print button at the top of your browser.
If you lose or forget your Reentry Number, you will have to begin this application again, and you will
lose all the information already entered. You can start a new application up to three times. Social
Security can help you start the process again, but we cannot look up the Reentry Number for you.
Last Date To Complete This Application
You need to complete an application by October 22, 2007; otherwise, you may lose benefits.
Important Information
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Sign Out
You might have received a notice from us advising you of an earlier time period for filing the
application. If you did, it was because you or someone on your behalf contacted us about filing
before you started the Internet application. Generally, it is to your advantage to file within that earlier
period to receive the earliest filing date.
Continue With This Application
Exit
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You Are Not Eligible For The Extra Help
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
You Are Not Eligible For The Extra Help
Based on the information you gave us about your combined savings, investments and real
estate, you are not eligible for extra help. You do not need to complete this application. However,
if you need a letter stating you are not eligible, complete the application. Whether or not you qualify
for the extra help, you may still enroll in an approved Medicare prescription drug plan for coverage.
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.
What You Can Do Next
1. You may begin the application process by selecting Apply Now,
2. You may go back to make changes by selecting Previous, or
3. You may Exit this application.
If you select Apply Now, you will get a Reentry Number after you fill in your name and address. If
you choose to Exit this application before it is complete, you may use your Reentry Number at any
time to come back. You will also be able to change your answers later.
What You Will Need
If you decide to complete this application, we will ask about your income (and your spouse's income,
if married and living together) and the things that you and your spouse own. Documents that may
help you prepare include:
●
Social Security card;
●
bank account statements, including checking, savings, and certificates of deposit;
●
Individual Retirement Accounts (IRA), stocks, bonds, savings bonds, mutual funds, other
investment statements;
●
tax returns;
●
payroll slips;
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You Are Not Eligible For The Extra Help
●
your most recent award letters or statements for Railroad Retirement income, Veterans
benefits, pensions and annuities; and
●
the cash and face values of any life insurance policies you have. Check with your insurance
agent for the exact amount you would get if you cashed in your life insurance policies today.
If you do not have these documents, provide us with your best estimate so that we can tell you
whether you are likely to qualify for extra help with your prescription drug costs. This information is
to help you complete the application. You will not have to submit the documents unless contacted by
a Social Security representative.
Previous
Apply Now
Exit
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Go Ahead
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Go Ahead
To complete the application, select Apply Now at the bottom of this page.
We will ask about your income, your spouse's income, and the things that you and your spouse
own. Documents that may help you prepare include:
●
Social Security card;
●
bank account statements, including checking, savings, and certificates of deposit;
●
Individual Retirement Accounts (IRA), stocks, bonds, savings bonds, mutual funds, other
investment statements;
●
tax returns;
●
payroll slips;
●
your most recent award letters or statements for Railroad Retirement income, Veterans
benefits, pensions and annuities; and
●
the cash and face values of any life insurance policies you have. Check with your insurance
agent for the exact amount you would get if you cashed in your life insurance policies today.
If you do not have these documents, provide us with your best estimate so that we can tell you
whether you are likely to qualify for extra help with your prescription drug costs. This information is
to help you complete the application. You will not have to submit the documents unless contacted by
a Social Security representative.
Previous
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Apply Now
Preparing To Find Out If You Qualify
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Preparing To Find Out If You Qualify
Do not use your browser's Back button.
To go back, select Previous at the bottom of the page.
What information will you need?
To determine if you could be eligible for help with prescription drug plan costs, Social Security needs
information about your (and your spouse's, if married and living together) income and resources.
Documents that may help you prepare include:
●
Social Security card;
●
bank account statements, including checking, savings, and certificates of deposit;
●
Individual Retirement Accounts (IRAs), stocks, bonds, savings bonds, mutual funds, other
investment statements;
●
tax returns;
●
payroll slips;
●
your most recent Social Security benefits award letters or statements for Railroad Retirement
income, Veterans Benefits, pensions and annuities; and
●
the cash value and face value of any life insurance policies you have. Check with your
insurance agent for the exact amount you would get if you cashed in your life insurance
policies today.
If you do not have these documents, provide us with your best estimate so that we can tell you
whether you are likely to qualify for extra help with your prescription drug costs. This information is
to help you complete the application. You will not have to submit the documents unless contacted by
a Social Security representative.
You may apply regardless of the Qualifier results. If you apply right away, the information you enter
will be saved in the application. Whatever you enter here will not affect your benefits or the
application decision; you can change your financial information when you enter the application.
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Preparing To Find Out If You Qualify
What if you need to stop and come back later?
If you select Apply Now, you will get a Reentry Number after you fill in your name and address. If
you choose to Sign Out of this application before it is complete, you may use your Reentry Number
at any time to come back. You will also be able to change your answers later.
Can you edit your information?
When you have completed the application, you will get a full summary of the information you
entered. You can make changes if necessary prior to submission. After you submit the application
electronically, you will be able to print or save a receipt, and your submitted application.
How long can you work on each page?
For security reasons, there are time limits on each page. You will receive a warning after 25 minutes
but you can extend your time on that page. After the third warning on a page, you must move to
another page or your time will run out and all your work on that page will be lost.
If you have turned JavaScript off in your browser, you will not receive these warnings and, after 30
minutes on a page, you must go to another page or your application session will end, and your work
on the last page will be lost.
If you are unsure about how to use this application, you can find more details on the following
pages:
●
How the Online Application Works
●
Special Instructions for Blind Users
Previous
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Continue
Preparing To Use This Application
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Preparing To Use This Application
Do not use your browser's Back button.
To go back, select Previous at the bottom of the page.
What information will you need?
To determine if you could be eligible for help with prescription drug plan costs, Social Security needs
information about your (and your spouse's, if married and living together) income and resources.
Documents that may help you prepare include:
●
Social Security card;
●
bank account statements, including checking, savings, and certificates of deposit;
●
Individual Retirement Accounts (IRAs), stocks, bonds, savings bonds, mutual funds, other
investment statements;
●
tax returns;
●
payroll slips;
●
your most recent award letters or statements for Railroad Retirement income, Veterans
benefits, pensions and annuities; and
●
the cash value and face value of any life insurance policies you have. Check with your
insurance agent for the exact amount you would get if you cashed in your life insurance
policies today.
If you do not have these documents, provide us with your best estimate so that we can tell you
whether you are likely to qualify for extra help with your prescription drug costs. This information is
to help you complete the application. You will not have to submit the documents unless contacted by
a Social Security representative.
What if you need to stop and come back later?
If you select Apply Now, you will get a Reentry Number after you fill in your name and address. If
you choose to Sign Out of this application before it is complete, you may use your Reentry Number
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Preparing To Use This Application
at any time to come back. You will also be able to change your answers later.
Can you edit your information?
When you have completed the application, you will get a full summary of the information you
entered. You can make changes if necessary prior to submission. After you submit the application
electronically, you will be able to print or save a receipt, and your submitted application.
How long can you work on each page?
For security reasons, there are time limits on each page. You will receive a warning after 25 minutes
but you can extend your time on that page. After the third warning on a page, you must move to
another page or your time will run out and all your work on that page will be lost.
If you have turned JavaScript off in your browser, you will not receive these warnings and, after 30
minutes on a page, you must go to another page or your application session will end, and your work
on the last page will be lost.
If you are unsure about how to use this application, you can find more details on the following
pages:
●
How the Online Application Works
●
Special Instructions for Blind Users
Previous
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Continue
Main Help Page
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Application Help
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.
Information About This Application
What Is This Application?
How Can You Get The Extra Help?
Who Should Complete This Application For Extra Help With Medicare Prescription Drug Plan Costs?
What Information Will You Need?
What If You Need To Stop And Come Back Later?
Can You Edit Your Information?
How Long Can You Work On Each Page?
Are There Other Ways To Apply?
Information About Medicare
Legal And Official Information
Information About This Application
Follow the links below for specific information regarding this application:
How The Online Application Works
Special Instructions For Blind Users
Back to Top
What Is This Application?
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Main Help Page
It is an application for extra help with the prescription drug costs. It does not enroll you in a
prescription drug plan. You will have to enroll directly with an approved Medicare prescription drug
provider for coverage. 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.
Back to Top
How Can You Get The Extra Help?
To get extra help with prescription drug costs, you must complete and submit this application.
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 this application, call Social Security toll-free at 1-800-772-1213. If you
are deaf or hard of hearing, call our toll-free TTY number at 1-800-325-0778.
If you need information about the new Medicare Prescription Drug Program, call 1-800-MEDICARE
(TTY 1-877-486-2048) or visit www.medicare.gov.
Back to Top
Who Should Complete This Application For Extra Help With Medicare Prescription
Drug Plan Costs?
You should complete this application for extra help on the Internet if:
●
You have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance);
and
●
You live in one of the 50 states or the District of Columbia; and
●
Your combined savings, investments, and real estate are not worth more than $23,410 if you
are married and living with your spouse, or $11,710 if you are not currently married or not
living with your spouse. (DO NOT include the home you live in, vehicles, personal
possessions, burial plots or irrevocable burial contracts.) If you have more than those
amounts, you may not qualify for the extra help. However, if there is any doubt about the
amounts, or you need a letter stating you are not eligible, complete the application. If you do
not qualify for the extra help, you can still enroll in an approved Medicare prescription drug
plan for coverage.
EXCEPTIONS: Even if you meet the conditions above, DO NOT complete this application if you
have Medicare and Supplemental Security Income (SSI) or Medicare and Medicaid because you
automatically will get the extra help.
If your state pays your Medicare premiums because you belong to a Medicare Savings Program,
you should contact your state Medicaid office for more information. You could get the extra help
automatically and may not need to complete this application.
Back to Top
What Information Will You Need?
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Main Help Page
To determine if you could be eligible for help with prescription drug plan costs, Social Security needs
information about your (and your spouse's, if married and living together) income and resources.
Documents that may help you prepare include:
●
Social Security card;
●
bank account statements, including checking, savings, and certificates of deposit;
●
Individual Retirement Accounts (IRA), stocks, bonds, savings bonds (including book entry
securities*), mutual funds, other investment statements;
●
tax returns;
●
payroll slips;
●
your most recent Social Security benefits award letters or statements for Railroad Retirement
income, Veterans benefits, pensions and annuities; and
●
the cash value and face value of any life insurance policies you have. Check with your
insurance agent for the exact amount you would get if you cashed in your life insurance
policies today.
* Book Entry Securities - In addition to traditional U.S. Savings Bonds, individuals now may go to
the Treasury Department's Internet site and make online purchases of electronic savings bonds.
Electronic savings bonds are also called "book entry securities." With book entry securities, the
individual's investment is recorded electronically by the Treasury Department and a paper savings
bond is not issued. If you have book entry securities, they are counted as resources and should be
reported on this application.
If you do not have these documents, provide us with your best estimate so that we can tell you
whether you are likely to qualify for extra help with your prescription drug costs. This information is
to help you complete the application. You will not have to submit the documents unless contacted by
a Social Security representative.
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What If You Need To Stop And Come Back Later?
If you select Apply Now, you will get a Reentry Number after you fill in your name and address. If
you choose to Sign Out of this application before it is complete, you may use your Reentry Number
at any time to come back. You will also be able to change your answers later.
Back to Top
Can You Edit Your Information?
When you have completed the application, you will get a full summary of the information you
entered. You can make changes if necessary prior to submission. After you submit the application
electronically, you will be able to print or save a receipt, and your submitted application.
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How Long Can You Work On Each Page?
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Main Help Page
For security reasons, there are time limits on each page. You will receive a warning after 25 minutes
but you can extend your time on that page. After the third warning on a page, you must move to
another page or your time will run out and all your work on that page will be lost.
If you have turned JavaScript off in your browser, you will not receive these warnings and, after 30
minutes on a page, you must go to another page or your application session will end, and your work
on the last page will be lost.
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Are There Other Ways To Apply?
If you prefer not to fill out this application on the Internet, you can call our toll-free
number, 1-800-772-1213 for a paper application. If you are deaf or hard of hearing, call our toll-free
TTY number, 1-800-325-0778. Representatives are available Monday through Friday from 7 a.m. to
7 p.m. Tell the representative that you want to apply for help with Medicare prescription drug costs.
Back to Top
Information About Medicare
Follow the links below for more specific information regarding the Prescription Drug Program and
Medicare:
About The Prescription Drug Program
Medicare Information:
Official U.S. Government Medicare Site
Centers For Medicare & Medicaid Services
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Legal And Official Information
Internet Security Policy
Website Policies & Other Important Information
Back to Top
Close this window to return to the application.
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Help: Should You Use This Application
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Should You Use This Application
Are you assisting someone (other than your spouse who lives with you) with this
application?
In order to collect the appropriate contact information, we need to know if this form is being filled out
by a third party. If you are assisting someone other than your spouse who lives with you, select Yes.
Did you (or your spouse, if married and living together) get an application in the mail
from us?
We mailed scannable paper applications for Help With Medicare Prescription Drug Plan Costs to
people who appeared to be below the income limits based on the information already in our records.
However, if an individual received an application, it does not mean that the individual automatically
qualifies for assistance.
Do you (or your spouse, if married and living together) have Medicare?
Only individuals who are eligible for, or have Medicare may use this application. If you (or your
spouse, if married and living together) are, you may be eligible for extra help to pay for your monthly
premiums, annual deductibles, and co-payments related to the prescription drug program.
Are you (or your spouse, if married and living together) 64 years and 9 months old or
older?
The purpose of this question is to help us determine if you may be eligible for Medicare. If you are
eligible for Medicare and have not yet applied, call our toll-free number at 1-800-772-1213. If you
are deaf or hard of hearing, call our toll-free TTY number at 1-800-325-0778.
Have you (or your spouse, if married and living together) received:
●
Social Security disability benefits for 24 months;
●
disability benefits based on Lou Gehrig's disease (ALS); or
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Help: Should You Use This Application
●
renal dialysis treatments or a kidney transplant?
The purpose of this question is to help us determine if you may be eligible for Medicare. To apply for
Medicare a person must:
●
be at least 64 years and 9 months old;
●
have received Social Security disability benefits for 24 months;
●
receive Social Security disability benefits based on Lou Gehrig's disease (ALS); or
●
have received renal dialysis treatments or a kidney transplant.
If you (or your spouse, if married and living together) are eligible for Medicare and have not yet
applied, call our toll-free number at 1-800-772-1213. If you are deaf or hard of hearing, call our tollfree TTY number at 1-800-325-0778.
In which state do you (or your spouse, if married and living together) live?
To be eligible for the help with prescription drug plan costs, you must live in one of the 50 states or
the District of Columbia. Select the state where your permanent residence is located.
What is your marital status?
If you are married and living with your spouse, we count the income and resources of both you and
your spouse when we determine whether you are eligible to receive help with prescription drug plan
costs. We consider that you are living together if you and your spouse live in the same household.
We count the income and resources of you and your spouse regardless of whether one or both of
you are filing for this help. We consider that you are still living together if you or your spouse are
temporarily absent from the household in a hospital or nursing home.
Do you have combined savings, investments, and real estate worth more than:
●
$23,410 if you are married and living with your spouse; or
●
$11,710 if you are not married or not living with your spouse?
To be eligible for help with prescription drug plan costs, your resources must be within certain limits.
Your resources may include bank accounts (checking, savings, and certificates of deposit), stocks,
bonds, savings bonds (including book entry securities*), mutual funds, Individual Retirement
Accounts (IRA), and any other cash at home or anywhere else. Your resources also include real
estate you own except for the home that you live in. Examples of other real estate are summer
homes, rental properties or undeveloped land you own. Include the things you own by yourself, with
your spouse or with someone else. DO NOT include vehicles, personal possessions, burial plots, or
irrevocable burial contracts.
If you are sure that your combined savings, investments, and real estate are worth more than
$23,410 (married) or $11,710 (single), select Yes. The actual limits for eligibility are $20,410
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Help: Should You Use This Application
(married) or $10,210 (single). However, since we may not count some of the resources you expect
to use for funeral or burial expenses, you may be able to have up to $23,410 (married) or $11,710
(single).
* Book Entry Securities - In addition to traditional U.S. Savings Bonds, individuals now may go to
the Treasury Department's Internet site and make online purchases of electronic savings bonds.
Electronic savings bonds are also called "book entry securities." With book entry securities, the
individual's investment is recorded electronically by the Treasury Department and a paper savings
bond is not issued. If you have book entry securities, they are counted as resources and should be
reported on this application.
Other examples of resources that should NOT be counted are:
●
Resources you could not easily convert to cash, such as jewelry or home furnishings;
●
Property you need for self support that is used in a trade or business;
●
The cash value of your life insurance if the total face value of the policies you own is $1,500
or less;
●
The cash value of your spouse's life insurance if the total face value of the policies he or she
owns is $1,500 or less;
●
Irrevocable burial trusts;
●
Disaster assistance;
●
Certain distributions received by an Alaska Native from an Alaska Native Regional and
Village Corporation;
●
Land held in trust by the United States for an individual Indian or tribe;
●
Funds held in trust by the Secretary of the Interior for an Indian tribe and distributed per
capita to members of the tribe;
●
Payments to members of specific Indian tribes as provided by Federal legislation; and
●
Up to $2,000 per year received by an Indian that is derived from individual interests in trust
or restricted lands.
NOTE: Certain other money you may be holding is not counted for nine months, such as:
●
Retroactive Social Security or Supplemental Security Income benefits;
●
Tax advances and refunds related to earned income tax credits and child tax credits;
●
Compensation you receive as a crime victim;
●
Relocation assistance from a state or local government; and
●
Scholarships and education grants.
Close this window to return to the application.
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Help: Find Out If You And Your Spouse Qualify: Part 1
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Find Out If You And Your Spouse Qualify: Part 1
Have you or your spouse worked in this calendar year?
If you or your spouse have worked at any time during the present calendar year, select Yes for this
question. If you have not worked at any time during the current calendar year, select No.
Are you or your spouse UNDER age 65?
If you or your spouse are under age 65, disabled or blind and working, we may be able to exclude
some of your earnings when we determine your eligibility for help with prescription drug costs. If you
spend part of your earnings to pay for things needed in order to work, we will not count those
earnings when we determine eligibility. For example, we would exclude the amount spent on
attendant care, certain drugs, medical supplies and devices, certain types of training and therapy,
certain work-related equipment, etc.
Not counting your spouse how many other relatives live in your household an receive at
least one-half of their financial support from you or your spouse? Do NOT include
yourself or your spouse in the number you enter. If your household consists only of you
and your spouse, enter "0."
Eligibility for the extra help is based on the amount of your income and that of your spouse
compared to the Federal Poverty Level for your household's size. Therefore, we need to know how
many other relatives are in your household for whom you or your spouse provide at least one-half of
their financial support. We count relatives related to you by blood, marriage or adoption.
Do you count on anyone to help pay for any of the following household expenses?
●
Food
●
Heating Fuel or Gas
●
Mortgage
●
Electricity and Water
●
Rent
●
Property Taxes
If anyone regularly provides you or your spouse with assistance with food or shelter costs, select
Yes. If Yes, also enter the average amount you receive each month in the space provided.
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Help: Find Out If You And Your Spouse Qualify: Part 1
If you receive help with these expenses for only part of the year, it will be necessary for you to
compute the average MONTHLY amount of this help.
Example:
A relative paid your heating bills during the winter months of January through March and your
heating bills were about $180 per month during those three months. This means that you received a
total of $540 in help during the year for your heating bills. However, you must enter the monthly
average amount of this help on your application. To compute the monthly amount, divide $540 by 12
months, which is $45, and enter $45 as the monthly amount of help you received.
If your heating bills were more than $193 per month, only use $193 when computing the average
monthly amount. (Any help you received over $193 per month is not counted.) So, if the heating bills
for January through March were about $300 per month, multiply $193 (not $300) by three months,
which totals $579 for the year. Then divide $579 by 12, which is $48.25, and enter $48.25 as the
monthly amount of help you received.
If you occasionally or unexpectedly receive small amounts of money or other help, such as your
child buying groceries for the week, do NOT include that amount. Other examples of possible
income sources that should NOT be counted are:
●
Food Stamps;
●
House repairs;
●
Help from a housing agency;
●
Help from an energy assistance program;
●
Meals on Wheels;
●
Contributions from food banks;
●
Soup kitchens;
●
Disaster assistance;
●
Help with your telephone bills; and
●
Help with medical bills, treatments and drugs.
Also, do NOT count any help you received before the month you file your application.
Close this window to return to the application.
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Help: Find Out If You Qualify: Part 1
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Find Out If You Qualify: Part 1
Have you worked in this calendar year?
If you have worked at any time during the present calendar year, select Yes for this question. If you
have not worked at any time during the current calendar year, select No.
Are you UNDER age 65?
If you are under age 65, disabled or blind and working, we may be able to exclude some of your
earnings when we determine your eligibility for help with prescription drug costs. If you spend part of
your earnings to pay for things needed in order to work, we will not count those earnings when we
determine eligibility. For example, we would exclude the amount spent on attendant care, certain
drugs, medical supplies and devices, certain types of training and therapy, certain work-related
equipment, etc.
How many relatives live in your household and receive at least one-half of their financial
support from you? Do NOT include yourself in the number you enter. If your household
consists only of you, enter "0."
Eligibility for the extra help is based on the amount of your income compared to the Federal Poverty
Level for your household's size. Therefore, we need to know how many relatives are in your
household for whom you provide at least one-half of their financial support. We count relatives
related to you by blood, marriage or adoption.
Do you count on anyone to help pay for any of the following household expenses?
●
Food
●
Heating Fuel or Gas
●
Mortgage
●
Electricity and Water
●
Rent
●
Property Taxes
If anyone regularly provides you with assistance with food or shelter costs, select Yes. If Yes, also
enter the average amount you receive each month in the space provided.
If you receive help with these expenses for only part of the year, it will be necessary for you to
compute the average MONTHLY amount of this help.
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Help: Find Out If You Qualify: Part 1
Example:
A relative paid your heating bills during the winter months of January through March and your
heating bills were about $180 per month during those three months. This means that you received a
total of $540 in help during the year for your heating bills. However, you must enter the monthly
average amount of this help on your application. To compute the monthly amount, divide $540 by 12
months, which is $45, and enter $45 as the monthly amount of help you received.
If your heating bills were more than $193 per month, only use $193 when computing the average
monthly amount. (Any help you received over $193 per month is not counted.) So, if the heating bills
for January through March were about $300 per month, multiply $193 (not $300) by three months,
which totals $579 for the year. Then divide $579 by 12, which is $48.25, and enter $48.25 as the
monthly amount of help you received.
If you occasionally or unexpectedly receive small amounts of money or other help, such as your
child buying groceries for the week, do NOT include that amount. Other examples of possible
income sources that should NOT be counted are:
●
Food Stamps;
●
House repairs;
●
Help from a housing agency;
●
Help from an energy assistance program;
●
Meals on Wheels;
●
Contributions from food banks;
●
Soup kitchens;
●
Disaster assistance;
●
Help with your telephone bills; and
●
Help with medical bills, treatment and drugs.
Also, do NOT count any help you received before the month you file your application.
Close this window to return to the application.
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Help: Find Out If You And Your Spouse Qualify: Part 3
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Find Out If You And Your Spouse Qualify: Part 3
Do you or your spouse have to pay for things that enable you to work?
We will only count part of your earnings toward the income limit if you:
●
work;
●
receive Social Security benefits based on a disability or blindness; and
●
have work-related expenses for which you are not reimbursed.
If you or your spouse receive Social Security benefits based on a disability or blindness and have
work-related expenses, select Yes. You will not need to tell us the amount of those expenses. We
will not count a percentage of your earnings. When we send you a letter that says whether you are
eligible for the extra help or not, we will also tell you how much of your earnings we did not count. If
you think the amount of work-related expenses we used was less than your actual work-related
expenses, you may contact us to tell us the actual amount of your expenses.
What do you or your spouse expect to earn in wages before taxes and deductions this
calendar year?
If you or your spouse expect to earn money for any labor or services you provide on an hourly, daily,
or piecework basis during this calendar year, select Wages of: and enter the amount BEFORE taxes
and deductions you think you will earn in the field provided. If you did not, and do not expect to earn
wages, select None. Do NOT include earned income tax credit payments you may have received.
What do you or your spouse expect your net earnings from self-employment to be this
calendar year?
If you or your spouse expect to have net earnings or a net loss from self-employment this year,
select the appropriate response and enter the NET amount you think it will be in the field provided.
Do NOT include earned income tax credit payments you may have received. If you were not, and do
not expect to be self-employed, select None.
Have you or your spouse stopped working in 2006 or 2007, or plan to stop working in 2007
or 2008?
If you or your spouse have stopped working in the past 24 months, or if you plan to stop working in
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Help: Find Out If You And Your Spouse Qualify: Part 3
the next year, select Yes and enter the month and year in the fields provided.
Close this window to return to the application.
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Help: Find Out If You Qualify: Part 3
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Find Out If You Qualify: Part 3
Do you have to pay for things that enable you to work?
We will only count part of your earnings toward the income limit if you:
●
work;
●
receive Social Security benefits based on a disability or blindness; and
●
have work-related expenses for which you are not reimbursed.
If you receive Social Security benefits based on a disability or blindness and have work-related
expenses, select Yes. You will not need to tell us the amount of those expenses. We will not count a
percentage of your earnings. When we send you a letter that says whether you are eligible for the
extra help or not, we will also tell you how much of your earnings we did not count. If you think the
amount of work-related expenses we used was less than your actual work-related expenses, you
may contact us to tell us the actual amount of your expenses.
What do you expect to earn in wages before taxes and deductions this calendar year?
If you expect to earn money for any labor or services you provide on an hourly, daily, or piecework
basis during this calendar year, select Wages of: and enter the amount BEFORE taxes and
deductions you think you will earn in the field provided. If you did not, and do not expect to earn
wages, select None. Do NOT include earned income tax credit payments you may have received.
What do you expect your net earnings from self-employment to be this calendar year?
If you expect to have net earnings or a net loss from self-employment this year, select the
appropriate response and enter the NET amount you think it will be in the field provided. Do NOT
include earned income tax credit payments you may have received. If you were not, and do not
expect to be self-employed, select None.
Have you stopped working in 2006 or 2007, or plan to stop working in 2007 or 2008?
If you have stopped working in the past 24 months, or if you plan to stop working in the next year,
select Yes and enter the month and year in the fields provided.
Close this window to return to the application.
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Help: Find Out If You and Your Spouse Qualify: Part 2
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Find Out If You and Your Spouse Qualify: Part 2
Do you or your spouse receive Social Security benefits?
If you or your spouse currently receive benefits from Social Security, enter the total amount received each month in this field.
To find out what amount to enter, use the amount on your annual cost-of-living adjustment letter you receive from
Social Security. This is the amount BEFORE the premium for Medicare Medical Insurance is deducted. Other types
of deductions could include voluntary Federal tax withholding, partial recovery of an overpayment, child support
payments, garnishment, etc. (This is NOT an all-inclusive list.)
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Help: Find Out If You and Your Spouse Qualify: Part 2
Do you or your spouse receive Railroad Retirement income?
If you or your spouse currently receive benefits from the Railroad Retirement Board, enter the total amount received each
month in this field. To find out what amount to enter, use the amount on your annual cost-of-living adjustment letter you
receive from the Railroad Retirement Board. This is the amount BEFORE the premium for Medicare Medical Insurance
is deducted. Other types of deductions could include voluntary Federal tax withholding, partial recovery of an overpayment,
child support payments, garnishment, etc. (This is NOT an all-inclusive list.)
Do you or your spouse receive Veterans benefits?
If you or your spouse currently receive benefits from the Department of Veterans Affairs, enter the total amount received
each month in this field. To find out what amount to enter, use the amount on your annual cost-of-living adjustment letter
you receive from the Department of Veterans Affairs. This is the amount BEFORE any deductions have been made. Types
of deductions could include voluntary Federal tax withholding, partial recovery of an overpayment, child support
payments, garnishment, etc. (This is NOT an all-inclusive list.)
Do you or your spouse receive income from other pensions or annuities?
If you or your spouse currently receive income from a pension, enter the total amount received each month in this field. If
you receive money from an insurance company (annuity) on a regular basis (monthly, yearly, etc.), enter that amount as
well. This includes immediate and deferred annuity payments, and is the amount BEFORE any deductions have been
made. Types of deductions could include voluntary Federal tax withholding, partial recovery of an overpayment, child
support payments, garnishment, etc. (This is NOT an all-inclusive list.)
The entry for this field must be shown in a MONTHLY format. If the pension or annuity is received other than monthly, convert
to a monthly amount before entering (e.g., if received weekly, multiply by 52 and divide by 12; if received bi-weekly, multiply
by 26 and divide by 12; if received yearly, divide by 12, etc.).
Do NOT include annuities from certificates of deposit, stocks, bonds, mutual funds, IRAs or any other investments.
Do you or your spouse receive other income not listed above, including alimony, net rental income,
workers' compensation, etc.?
Indicate whether you or your spouse receive income from any other source. 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.
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings bonds, mutual funds,
IRAs or any similar investments, or any other cash at home or anywhere else.)
Do NOT list wages and self-employment, interest income, public assistance, medical reimbursements, or foster care
payments here. Other examples of possible income sources that should NOT be counted are:
●
Food Stamps;
●
House repairs;
●
Help from an energy assistance program;
●
Help with medical bills, treatment and drugs;
●
Help from a housing agency;
●
Disaster assistance;
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Help: Find Out If You and Your Spouse Qualify: Part 2
●
Meals on Wheels;
●
Contributions from food banks;
●
Soup kitchens;
●
Earned income tax credit payments;
●
Victim's compensation payments;
●
Scholarships and education grants;
●
Certain distributions received by an Alaska Native from an Alaska Native Regional and Village Corporation;
●
Land held in trust by the United States for an individual Indian or tribe;
●
Funds held in trust by the Secretary of the Interior for an Indian tribe and distributed per capita to members of the tribe;
●
Payments to members of specific Indian tribes as provided by Federal legislation; and
●
Up to $2,000 per year received by an Indian that is derived from individual interests in trust or restricted lands.
Close this window to return to the application.
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Help: Find Out If You Qualify: Part 2
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Find Out If You Qualify: Part 2
Do you receive Social Security benefits?
If you currently receive benefits from Social Security, enter the total amount received each month in this field. To find out
what amount to enter, use the amount on your annual cost-of-living adjustment letter you receive from Social Security. This
is the amount BEFORE the premium for Medicare Medical Insurance is deducted. Other types of deductions could
include voluntary Federal tax withholding, partial recovery of an overpayment, child support payments, garnishment, etc. (This
is NOT an all-inclusive list.)
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Help: Find Out If You Qualify: Part 2
Do you receive Railroad Retirement income?
If you currently receive benefits from the Railroad Retirement Board, enter the total amount received each month in this field.
To find out what amount to enter, use the amount on your annual cost-of-living adjustment letter you receive from the
Railroad Retirement Board. This is the amount BEFORE the premium for Medicare Medical Insurance is deducted. Other
types of deductions could include voluntary Federal tax withholding, partial recovery of an overpayment, child support
payments, garnishment, etc. (This is NOT an all-inclusive list.)
Do you receive Veterans benefits?
If you currently receive benefits from the Department of Veterans Affairs, enter the total amount received each month in
this field. To find out what amount to enter, use the amount on your annual cost-of-living adjustment letter you receive from
the Department of Veterans Affairs. This is the amount BEFORE any deductions have been made. Types of deductions
could include voluntary Federal tax withholding, partial recovery of an overpayment, child support payments, garnishment,
etc. (This is NOT an all-inclusive list.)
Do you receive income from other pensions or annuities?
If you currently receive income from a pension, enter the total amount received each month in this field. If you receive
money from an insurance company (annuity) on a regular basis (monthly, yearly, etc.), enter that amount as well. This
includes immediate and deferred annuity payments, and is the amount BEFORE any deductions have been made. Types
of deductions could include voluntary Federal tax withholding, partial recovery of an overpayment, child support
payments, garnishment, etc. (This is NOT an all-inclusive list.)
The entry for this field must be shown in a MONTHLY format. If the pension or annuity is received other than monthly, convert
to a monthly amount before entering (e.g., if received weekly, multiply by 52 and divide by 12; if received bi-weekly, multiply
by 26 and divide by 12; if received yearly, divide by 12, etc.).
Do NOT include annuities from certificates of deposit, stocks, bonds, mutual funds, IRAs or any other investments.
Do you receive other income not listed above, including alimony, net rental income, workers' compensation, etc.?
Indicate whether you receive income from any other source. 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.
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings bonds, mutual funds,
IRAs or any similar investments, or any other cash at home or anywhere else.)
Do NOT list wages and self-employment, interest income, public assistance, medical reimbursements, or foster care
payments here. Other examples of possible income sources that should NOT be counted are:
●
Food Stamps;
●
House repairs;
●
Help from an energy assistance program;
●
Help with medical bills, treatment and drugs;
●
Help from a housing agency;
●
Disaster assistance;
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Help: Find Out If You Qualify: Part 2
●
Meals on Wheels;
●
Contributions from food banks;
●
Soup kitchens;
●
Earned income tax credit payments;
●
Victim's compensation payments;
●
Scholarships and education grants;
●
Certain distributions received by an Alaska Native from an Alaska Native Regional and Village Corporation;
●
Land held in trust by the United States for an individual Indian or tribe;
●
Funds held in trust by the Secretary of the Interior for an Indian tribe and distributed per capita to members of the tribe;
●
Payments to members of specific Indian tribes as provided by Federal legislation; and
●
Up to $2,000 per year received by an Indian that is derived from individual interests in trust or restricted lands.
Close this window to return to the application.
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Help: About You And Your Spouse
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: About You And Your Spouse
Your Name:
To ensure your privacy, we must match the name you enter on this application to the name on your
most recent Social Security card. Therefore, it is very important that you enter it exactly the same
way. If we cannot match these names, you will be unable to file for this extra help on the Internet.
Your Social Security Number:
Enter your own Social Security number. If you receive Social Security benefits based on someone
else's Social Security number, such as a current, former, or deceased spouse, do not enter that
individual's Social Security number or Medicare Claim Number in this field.
What is your date of birth?
We use this date to determine your current age. If you are under age 65, blind or disabled and
working, we may be able to exclude some of your earnings when we determine eligibility for help
with prescription drug costs. If you spend part of your earnings to pay for things needed in order to
work, we will not count those earnings when we determine eligibility. For example, we would
exclude the amount spent on attendant care, certain drugs, medical supplies and devices, certain
types of training and therapy, certain work-related equipment, etc.
Have you worked in 2006 or 2007?
When we determine whether you are eligible for help with prescription drug plan costs, we consider
the wages and self-employment net earnings that you or your spouse receive.
If you or your spouse worked in 2006 or 2007, we will ask you about your wages and selfemployment earnings when you complete the application for this help.
If neither you nor your spouse worked in these years, we will not ask you about your wages and selfemployment earnings when you complete the application for this help.
If you worked in 2006 or 2007, select Yes.
Spouse's Name:
To ensure your spouse's privacy, we must match the name entered on this application to the name
on his or her most recent Social Security card. Therefore, it is very important that you enter it exactly
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Help: About You And Your Spouse
the same way. If we cannot match these names, you will be unable to file for this extra help for your
spouse on the Internet.
Spouse's Social Security Number:
Enter your spouse's own Social Security number. If your spouse receives Social Security benefits
based on someone else's Social Security number, such as yours or a former or deceased spouse,
do not enter your or the former spouse's Social Security number or Medicare Claim number in this
field.
What is your spouse's date of birth?
We use this date to determine your spouse's current age. If your spouse is under age 65, blind or
disabled and working, we may be able to exclude some of his or her earnings when we determine
eligibility for help with prescription drug costs. If your spouse spends part of his or her earnings to
pay for things needed in order to work, we will not count those earnings when we determine
eligibility. For example, we would exclude the amount spent on attendant care, certain drugs,
medical supplies and devices, certain types of training and therapy, certain work-related equipment,
etc.
Has your spouse worked in 2006 or 2007?
When we determine eligibility for help with prescription drug plan costs, we consider the wages and
self-employment net earnings that you or your spouse receive.
If you or your spouse worked in 2006 or 2007, we will ask you about your wages and selfemployment earnings when you complete the application for this help.
If neither you nor your spouse worked in these years, we will not ask you about your wages and selfemployment earnings when you complete the application for this help.
If your spouse worked in 2006 or 2007, select Yes.
Your Mailing Address:
All notices sent to you from Social Security will be mailed to the address we currently have on file. If
you have moved in the last three months, check the box to indicate this is a new address. Your
mailing address must be within the 50 states or the District of Columbia.
Your Phone Number:
Only phone numbers within the 50 states or the District of Columbia will be accepted in this field.
If your spouse has Medicare (or expects to have it in the next three months), does he or
she also wish to apply?
If both you and your spouse have Medicare (or expect to have it in the next three months), you may
both apply for the extra help on the same application.
Select Yes if your spouse is also applying. Select No if your spouse is not applying.
Do you have combined savings, investments, and real estate worth more than $23,410?
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Help: About You And Your Spouse
To be eligible for help with prescription drug plan costs, your resources must be within certain limits.
Your resources include bank accounts (checking, savings, and certificates of deposit), stocks,
bonds, savings bonds (including book entry securities*), mutual funds, Individual Retirement
Accounts (IRA), and any other cash at home or anywhere else. Your resources also include real
estate you own, except for the home that you live in. Examples of other real estate are summer
homes, rental properties or undeveloped land they own. Include the things you own by yourself, with
your spouse or with someone else. Do NOT include vehicles, personal possessions, burial plots or
irrevocable burial contracts.
If you are sure that your combined savings, investments, and real estate are worth more than
$23,410, select Yes. The actual limit for eligibility is $20,410. However, since we may not count
some of the resources you expect to use for funeral or burial expenses, you may be able to have up
to $23,410.
* Book Entry Securities - In addition to traditional U.S. Savings Bonds, individuals now may go to
the Treasury Department's Internet site and make online purchases of electronic savings bonds.
Electronic savings bonds are also called "book entry securities." With book entry securities, the
individual's investment is recorded electronically by the Treasury Department and a paper savings
bond is not issued. If you have book entry securities, they are counted as resources and should be
reported on this application.
Other examples of resources that should NOT be counted are:
●
Resources you could not easily convert to cash, such as jewelry or home furnishings;
●
Property you need for self support that is used in a trade or business;
●
The cash value of your life insurance if the total face value of the policies you own is $1,500
or less;
●
The cash value of your spouse's life insurance if the total face value of the policies he or she
owns is $1,500 or less;
●
Irrevocable burial trusts;
●
Disaster assistance;
●
Certain distributions received by an Alaska Native from an Alaska Native Regional and
Village Corporation;
●
Land held in trust by the United States for an individual Indian or tribe;
●
Funds held in trust by the Secretary of the Interior for an Indian tribe and distributed per
capita to members of the tribe;
●
Payments to members of specific Indian tribes as provided by Federal legislation; and
●
Up to $2,000 per year received by an Indian that is derived from individual interests in trust
or restricted lands.
NOTE: Certain other money you may be holding is not counted for nine months, such as:
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Help: About You And Your Spouse
●
Retroactive Social Security or Supplemental Security Income benefits;
●
Tax advances and refunds related to earned income tax credits and child tax credits;
●
Compensation you receive as a crime victim;
●
Relocation assistance from a state or local government; and
●
Scholarships and education grants.
OPTIONAL: (contact person)
If there is someone that we should contact instead of you regarding the information you provided on
this form, please provide his or her name and phone number. If you provide contact information for
someone other than yourself, we will only contact that person by phone.
Contact's Phone Number:
Only phone numbers within the 50 states or the District of Columbia will be accepted in this field.
Close this window to return to the application.
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Help: About You
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: About You
Your Name:
To ensure your privacy, we must match the name you enter on this application to the name on your
most recent Social Security card. Therefore, it is very important that you enter it exactly the same
way. If we cannot match these names, you will be unable to file for this extra help on the Internet.
Your Social Security Number:
Enter your own Social Security number. If you receive Social Security benefits based on someone
else's Social Security number, such as a current, former, or deceased spouse, do not enter that
individual's Social Security number or Medicare Claim Number in this field.
What is your date of birth?
We use this date to determine your current age. If you are under age 65, blind or disabled and
working, we may be able to exclude some of your earnings when we determine eligibility for help
with prescription drug costs. If you spend part of your earnings to pay for things needed in order to
work, we will not count those earnings when we determine eligibility. For example, we would
exclude the amount spent on attendant care, certain drugs, medical supplies and devices, certain
types of training and therapy, certain work-related equipment, etc.
Have you worked in 2006 or 2007?
When we determine whether you are eligible for help with prescription drug plan costs, we consider
the wages and self-employment net earnings that you receive.
If you worked in 2006 or 2007, we will ask you about your wages and self-employment earnings
when you complete the application for this help.
If you did not work in these years, we will not ask you about your wages and self-employment
earnings when you complete the application for this help.
If you worked in 2006 or 2007, select Yes.
Your Mailing Address:
All notices sent to you from Social Security will be mailed to the address we currently have on file. If
you have moved in the last three months, check the box to indicate this is a new address. Your
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Help: About You
mailing address must be within the 50 states or the District of Columbia.
Your Phone Number:
Only phone numbers within the 50 states or the District of Columbia will be accepted in this field.
OPTIONAL: (contact person)
If there is someone that we should contact instead of you regarding the information you provided on
this form, please provide his or her name and phone number. If you provide contact information for
someone other than yourself, we will only contact that person by phone.
Contact's Phone Number:
Only phone numbers within the 50 states or the District of Columbia will be accepted in this field.
Do you have combined savings, investments, and real estate worth more than $11,710?
To be eligible for help with prescription drug plan costs, your resources must be within certain limits.
Your resources include bank accounts (checking, savings, and certificates of deposit), stocks,
bonds, savings bonds (including book entry securities*), mutual funds, Individual Retirement
Accounts (IRA), and any other cash at home or anywhere else. Your resources also include real
estate you own, except for the home that you live in. Examples of other real estate are summer
homes, rental properties or undeveloped land you own. Include the things you own by yourself or
with someone else. Do NOT include vehicles, personal possessions, burial plots or irrevocable
burial contracts.
If you are sure that your savings, investments, and real estate are worth more than $11,710, select
Yes. The actual limit for eligibility is $10,210. However, since we may not count some of the
resources you expect to use for funeral or burial expenses, you may be able to have up to $11,710.
* Book Entry Securities - In addition to traditional U.S. Savings Bonds, individuals now may go to
the Treasury Department's Internet site and make online purchases of electronic savings bonds.
Electronic savings bonds are also called "book entry securities." With book entry securities, the
individual's investment is recorded electronically by the Treasury Department and a paper savings
bond is not issued. If you have book entry securities, they are counted as resources and should be
reported on this application.
Other examples of resources that should NOT be counted are:
●
Resources you could not easily convert to cash, such as jewelry or home furnishings;
●
Property you need for self support that is used in a trade or business;
●
The cash value of your life insurance if the total face value of the policies you own is $1,500
or less;
●
Irrevocable burial trusts;
●
Disaster assistance;
●
Certain distributions received by an Alaska Native from an Alaska Native Regional and
Village Corporation;
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Help: About You
●
Land held in trust by the United States for an individual Indian or tribe;
●
Funds held in trust by the Secretary of the Interior for an Indian tribe and distributed per
capita to members of the tribe;
●
Payments to members of specific Indian tribes as provided by Federal legislation; and
●
Up to $2,000 per year received by an Indian that is derived from individual interests in trust
or restricted lands.
NOTE: Certain other money you may be holding is not counted for nine months, such as:
●
Retroactive Social Security or Supplemental Security Income benefits;
●
Tax advances and refunds related to earned income tax credits and child tax credits;
●
Compensation you receive as a crime victim;
●
Relocation assistance from a state or local government; and
●
Scholarships and education grants.
Close this window to return to the application.
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Help: About The Person Completing This Form And The People You Are Helping
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: About The Person Completing This Form And The People You
Are Helping
Relationship to Applicant:
In order to understand who is completing this form, we need to know who is providing the
information and your relationship to the people for whom you are applying. Please select the choice
from the drop-down menu that best reflects your relationship to the people for whom you are
applying.
Form Completer's Phone Number:
Only phone numbers within the 50 states or the District of Columbia will be accepted in this field.
Form Completer's Address:
If you are working for an organization or agency that is completing this form on behalf of another
individual, enter the business address in this field. Otherwise, enter your home address.
Your mailing address must be within the 50 states or the District of Columbia.
Primary Applicant's Name:
To ensure the primary applicant's privacy, we must match the name entered on this application to
the name on his or her most recent Social Security card. Therefore, it is very important that you
enter it exactly the same way. If we cannot match these names, you will be unable to file for this
extra help on the Internet.
Primary Applicant's Social Security Number:
Enter the primary applicant's own Social Security number. If the person for whom you are applying
receives Social Security benefits based on someone else's Social Security number, such as a
current, former or deceased spouse, do not enter that individual's Social Security number or
Medicare Claim Number in this field.
What is the primary applicant's date of birth?
We use this date to determine the primary applicant's current age. If the person for whom you are
applying is under age 65, blind or disabled and working, we may be able to exclude some of his or
her earnings when we determine eligibility for help with prescription drug costs. If he or she spends
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Help: About The Person Completing This Form And The People You Are Helping
part of his or her earnings to pay for things needed in order to work, we will not count those earnings
when we determine eligibility. For example, we would exclude the amount spent on attendent care,
certain drugs, medical supplies and devices, certain types of training and therapy, certain workrelated equipment, etc.
Has the primary applicant worked in 2006 or 2007?
When we determine eligibility for help with prescription drug plan costs, we consider the wages and
self-employment net earnings of the person who is applying for this help. We also consider the
wages and net self-employment earnings of that person's spouse.
If the primary applicant or his or her spouse worked in 2006 or 2007, we will ask about wages and
self-employment earnings on this application.
If neither the primary applicant nor his or her spouse worked in these years, we will not ask about
wages and self-employment earnings on this application.
If the primary applicant worked in 2006 or 2007, select Yes.
If the spouse has Medicare (or expects to have it in the next three months), does he or she
also wish to apply?
If both the applicant and his or her spouse have Medicare (or expect to have it within the next three
months), you may apply for both individuals on the same application.
Select Yes if the spouse is also applying. Select No if the spouse is not applying.
Do the applicants have combined savings, investments, and real estate worth more than
$23,410?
To be eligible for help with prescription drug plan costs, the resources of the person for whom you
are applying and his or her spouse must be within certain limits. Resources include bank accounts
(checking, savings, and certificates of deposit), stocks, bonds, savings bonds (including book entry
securities*), mutual funds, Individual Retirement Accounts (IRA), and any other cash at home or
anywhere else. Resources also include real estate owned, except for the home in which the
applicants live. Examples of other real estate are summer homes, rental properties or undeveloped
land they own. Include things the person for whom you are applying owns by himself or herself, with
his or her spouse or with someone else. Do NOT include vehicles, personal possessions, burial
plots or irrevocable burial contracts.
If you are sure that their savings, investments, and real estate are worth more than $23,410, select
Yes. The actual limit for eligibility is $20,410. However, since we may not count some of the
resources these people expect to use for funeral or burial expenses, they may be able to have up to
$23,410.
* Book Entry Securities - In addition to traditional U.S. Savings Bonds, individuals now may go to
the Treasury Department's Internet site and make online purchases of electronic savings bonds.
Electronic savings bonds are also called "book entry securities." With book entry securities, the
individual's investment is recorded electronically by the Treasury Department and a paper savings
bond is not issued. If the applicants have book entry securities, they are counted as resources and
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Help: About The Person Completing This Form And The People You Are Helping
should be reported on this application.
Other examples of resources that should NOT be counted are:
●
Resources they could not easily convert to cash, such as jewelry or home furnishings;
●
Property they need for self support that is used in a trade or business;
●
The cash value of the primary applicant's life insurance if the total face value of the policies
he or she owns is $1,500 or less;
●
The cash value of the spouse's life insurance if the total face value of the policies he or she
owns is $1,500 or less;
●
Irrevocable burial trusts;
●
Disaster assistance;
●
Certain distributions received by an Alaska Native from an Alaska Native Regional and
Village Corporation;
●
Land held in trust by the United States for an individual Indian or tribe;
●
Funds held in trust by the Secretary of the Interior for an Indian tribe and distributed per
capita to members of the tribe;
●
Payments to members of specific Indian tribes as provided by Federal legislation; and
●
Up to $2,000 per year received by an Indian that is derived from individual interests in trust
or restricted lands.
NOTE: Certain other money they may be holding is not counted for nine months, such as:
●
Retroactive Social Security or Supplemental Security Income benefits;
●
Tax advances and refunds related to earned income tax credits and child tax credits;
●
Compensation received as a crime victim;
●
Relocation assistance from a state or local government; and
●
Scholarships and education grants.
Spouse's Name:
To ensure the spouse's privacy, we must match the name entered on this application to the name
on his or her most recent Social Security card. Therefore, it is very important that you enter it exactly
the same way. If we cannot match these names, you will be unable to file for this extra help for the
spouse on the Internet.
Spouse's Social Security Number:
Enter the spouse's own Social Security number. If the spouse receives Social Security benefits
based on someone else's Social Security number, such as his or her current spouse or a former
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Help: About The Person Completing This Form And The People You Are Helping
spouse, do not enter the spouse's or former spouse's Social Security number or Medicare Claim
Number in this field.
What is the spouse's date of birth?
We use this date to determine the spouse's current age. If the spouse of the person for whom you
are applying is under age 65, blind or disabled and working, we may be able to exclude some of his
or her earnings when we determine eligibility for help with prescription drug costs. If he or she
spends part of his or her earnings to pay for things needed in order to work, we will not count those
earnings when we determine eligibility. For example, we would exclude the amount spent on
attendant care, certain drugs, medical supplies and devices, certain types of training and therapy,
certain work-related equipment, etc.
Has the applicant's spouse worked in 2006 or 2007?
When we determine eligibility for help with prescription drug plan costs, we consider the wages and
self-employment net earnings of the person who is applying for this help. We also consider the
wages and net self-employment earnings of that person's spouse.
If the primary applicant or his or her spouse worked in 2006 or 2007, we will ask about wages and
self-employment earnings on this application.
If neither the primary applicant nor his or her spouse worked in these years, we will not ask about
wages and self-employment earnings on this application.
If the primary applicant's spouse worked in 2006 or 2007, select Yes.
Mailing Address:
All notices sent from Social Security to the people for whom you are applying will be mailed to the
address we currently have on file. If the people for whom you are applying have moved in the last
three months, check the appropriate address-change box. This address must be within the 50 states
or the District of Columbia.
Phone Number:
Only phone numbers within the 50 states or the District of Columbia will be accepted in this field.
OPTIONAL: (contact person)
If there is someone that we should contact instead of you regarding the information you provided on
this form, please provide his or her name and phone number. If you provide contact information for
someone other than yourself, we will only contact that person by phone.
Contact's Phone Number:
Only phone numbers within the 50 states or the District of Columbia will be accepted in this field.
Close this window to return to the application.
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Help: About The Person Completing This Form And The Person You Are Helping
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: About The Person Completing This Form And The Person You
Are Helping
Relationship to Applicant:
In order to understand who is completing this form, we need to know who is providing the
information and your relationship to the person for whom you are applying. Please select the choice
from the drop-down menu that best reflects your relationship to the person for whom you are
applying.
Form Completer's Phone Number:
Only phone numbers within the 50 states or the District of Columbia will be accepted in this field.
Form Completer's Address:
If you are working for an organization or agency that is completing this form on behalf of another
individual, enter the business address in this field. Otherwise, enter your home address.
Your mailing address must be within the 50 states or the District of Columbia.
Applicant's Name:
To ensure the applicant's privacy, we must match the name entered on this application to the name
on his or her most recent Social Security card. Therefore, it is very important that you enter it exactly
the same way. If we cannot match these names, you will be unable to file for this extra help on the
Internet.
Applicant's Social Security Number:
Enter the applicant's own Social Security number. If the person for whom you are applying receives
Social Security benefits based on someone else’s Social Security number, such as a current, former
or deceased spouse, do not enter that individual's Social Security number or Medicare Claim
Number in this field.
What is the applicant's date of birth?
We use this date to determine the applicant's current age. If the person for whom you are applying
is under age 65, blind or disabled and working, we may be able to exclude some of his or her
earnings when we determine eligibility for help with prescription drug costs. If he or she spends part
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Help: About The Person Completing This Form And The Person You Are Helping
of his or her earnings to pay for things needed in order to work, we will not count those earnings
when we determine eligibility. For example, we would exclude the amount spent on attendant care,
certain drugs, medical supplies and devices, certain types of training and therapy, certain workrelated equipment, etc.
Has the applicant worked in 2006 or 2007?
When we determine eligibility for help with prescription drug plan costs, we consider the wages and
self-employment net earnings of the person who is applying for this help.
If the person you are helping worked in 2006 or 2007, we will ask about his or her wages and selfemployment earnings on this application.
If this person did not work in these years, we will not ask about wages and self-employment
earnings on this application.
If the person you are helping worked in 2006 or 2007, select Yes.
Mailing Address:
All notices sent from Social Security to the person for whom you are applying will be mailed to the
address we currently have on file. If the person for whom you are applying has moved in the last
three months, check the appropriate address-change box. This address must be within the 50 states
or the District of Columbia.
Phone Number:
Only phone numbers within the 50 states or the District of Columbia will be accepted in this field.
OPTIONAL: (contact person)
If there is someone that we should contact instead of you regarding the information you provided on
this form, please provide his or her name and phone number. If you provide contact information for
someone other than yourself, we will only contact that person by phone.
Contact's Phone Number:
Only phone numbers within the 50 states or the District of Columbia will be accepted in this field.
Does the applicant have combined savings, investments, and real estate worth more than
$11,710?
To be eligible for help with prescription drug plan costs, the applicant's resources must be within
certain limits. Resources include bank accounts (checking, savings, and certificates of deposit),
stocks, bonds, savings bonds (including book entry securities*), mutual funds, Individual Retirement
Accounts (IRA), and any other cash at home or anywhere else. Resources also include real estate
owned, except for the home in which the applicant lives. Examples of other real estate are
summer homes, rental properties or undeveloped land he or she owns. Include things the person for
whom you are applying owns by himself or herself or with someone else. Do NOT include vehicles,
personal possessions, burial plots or irrevocable burial contracts.
If you are sure that this person's combined savings, investments, and real estate are worth more
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Help: About The Person Completing This Form And The Person You Are Helping
than $11,710, select Yes. The actual limit for eligibility is $10,210. However, since we may not count
some of the resources the applicant expects to use for funeral or burial expenses, he or she may be
able to have up to $11,710.
* Book Entry Securities - In addition to traditional U.S. Savings Bonds, individuals now may go to
the Treasury Department's Internet site and make online purchases of electronic savings bonds.
Electronic savings bonds are also called "book entry securities." With book entry securities, the
individual's investment is recorded electronically by the Treasury Department and a paper savings
bond is not issued. If the applicant has book entry securities, they are counted as resources and
should be reported on this application.
Other examples of resources that should NOT be counted are:
●
Resources that could not easily convert to cash, such as jewelry or home furnishings;
●
Property he or she needs for self support that is used in a trade or business;
●
The cash value of his or her life insurance if the total face value of the policies owned is
$1,500 or less;
●
Irrevocable burial trusts;
●
Disaster assistance;
●
Certain distributions received by an Alaska Native from an Alaska Native Regional and
Village Corporation;
●
Land held in trust by the United States for an individual Indian or tribe;
●
Funds held in trust by the Secretary of the Interior for an Indian tribe and distributed per
capita to members of the tribe;
●
Payments to members of specific Indian tribes as provided by Federal legislation; and
●
Up to $2,000 per year received by an Indian that is derived from individual interests in trust
or restricted lands.
NOTE: Certain other money he or she may be holding is not counted for nine months, such as:
●
Retroactive Social Security or Supplemental Security Income benefits;
●
Tax advances and refunds related to earned income tax credits and child tax credits;
●
Compensation received as a crime victim;
●
Relocation assistance from a state or local government; and
●
Scholarships and education grants.
Close this window to return to the application.
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Help: About Your And Your Spouse's Living Situation
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: About Your And Your Spouse's Living Situation
Not counting your spouse, how many other relatives live in your household and receive at
least one-half of their financial support from you or your spouse? Do NOT include
yourself or your spouse in the number you enter. If your household consists only of you
and your spouse, enter "0."
Eligibility for the extra help is based on the amount of your income and that of your spouse
compared to the Federal Poverty Level for your household's size. Therefore, we need to know how
many other relatives are in your household for whom you or your spouse provide at least one-half of
their financial support. We count relatives related to you by blood, marriage or adoption.
Do you count on anyone to help pay for any of the following household expenses?
●
Food
●
Heating Fuel or Gas
●
Mortgage
●
Electricity and Water
●
Rent
●
Property Taxes
If anyone regularly provides you or your spouse with assistance with your food or shelter costs,
select Yes. If Yes, also enter the average amount you receive each month in the space provided.
If you receive help with these expenses for only part of the year, it will be necessary for you to
compute the average MONTHLY amount of this help.
Example:
A relative paid your heating bills during the winter months of January through March and your
heating bills were about $180 per month during those three months. This means that you received a
total of $540 in help during the year for your heating bills. However, you must enter the monthly
average amount of this help on your application. To compute the monthly amount, divide $540 by 12
months, which is $45, and enter $45 as the monthly amount of help you received.
If your heating bills were more than $193 per month, only use $193 when computing the average
monthly amount. (Any help you received over $193 per month is not counted.) So, if the heating bills
for January through March were about $300 per month, multiply $193 (not $300) by three months,
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Help: About Your And Your Spouse's Living Situation
which totals $579 for the year. Then divide $579 by 12, which is $48.25, and enter $48.25 as the
monthly amount of help you received.
If you occasionally or unexpectedly receive small amounts of money or other help, such as your
child buying groceries for the week, do NOT include that amount. Other examples of possible
income sources that should NOT be counted are:
●
Food Stamps;
●
House repairs;
●
Help from a housing agency;
●
Help from an energy assistance program;
●
Meals on Wheels;
●
Contributions from food banks;
●
Soup kitchens;
●
Disaster assistance;
●
Help with your telephone bills; and
●
Help with medical bills, treatment and drugs.
Also, do NOT count any help you received before the month you file your application.
Close this window to return to the application.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/hlp007a.html (2 of 2) [9/10/2007 7:30:00 AM]
Help: About Your Living Situation
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: About Your Living Situation
How many relatives live in your household and receive at least one-half of their financial
support from you? Do NOT include yourself in the number you enter. If your household
consists only of you, enter "0."
Eligibility for the extra help is based on the amount of your income compared to the Federal Poverty
Level for your household's size. Therefore, we need to know how many relatives are in your
household for whom you provide at least one-half of their financial support. We count relatives
related to you by blood, marriage or adoption.
Do you count on anyone to help pay for any of the following household expenses?
●
Food
●
Heating Fuel or Gas
●
Mortgage
●
Electricity and Water
●
Rent
●
Property Taxes
If anyone regularly provides you with assistance with your food or shelter costs, select Yes. If Yes,
also enter the average amount you receive each month in the space provided.
If you receive help with these expenses for only part of the year, it will be necessary for you to
compute the average MONTHLY amount of this help.
Example:
A relative paid your heating bills during the winter months of January through March and your
heating bills were about $180 per month during those three months. This means that you received a
total of $540 in help during the year for your heating bills. However, you must enter the monthly
average amount of this help on your application. To compute the monthly amount, divide $540 by 12
months, which is $45, and enter $45 as the monthly amount of help you received.
If your heating bills were more than $193 per month, only use $193 when computing the average
monthly amount. (Any help you received over $193 per month is not counted.) So, if the heating bills
for January through March were about $300 per month, multiply $193 (not $300) by three months,
which totals $579 for the year. Then divide $579 by 12, which is $48.25, and enter $48.25 as the
monthly amount of help you received.
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Help: About Your Living Situation
If you occasionally or unexpectedly receive small amounts of money or other help, such as your
child buying groceries for the week, do NOT include that amount. Other examples of possible
income sources that should NOT be counted are:
●
Food Stamps;
●
House repairs;
●
Help from a housing agency;
●
Help from an energy assistance program;
●
Meals on Wheels;
●
Contributions from food banks;
●
Soup kitchens;
●
Disaster assistance;
●
Help with your telephone bills; and
●
Help with medical bills, treatment and drugs.
Also, do NOT count any help you received before the month you file your application.
Close this window to return to the application.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/hlp007b.html (2 of 2) [9/10/2007 7:30:01 AM]
Help: Wages And Earnings
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Wages And Earnings
What do you or your spouse expect to earn in wages before taxes and deductions this
calendar year?
If you or your spouse expect to earn money for any labor or services you provide on an hourly, daily,
or piecework basis during this calendar year, select Wages of: and enter the amount BEFORE taxes
and deductions you think you will earn in the field provided. If you did not, and do not expect to earn
wages, select None. Do NOT include earned income tax credit payments you may have received.
What do you or your spouse expect your net earnings from self-employment to be this
calendar year?
If you or your spouse expect to have net earnings or a net loss from self-employment for this year,
select the appropriate response and enter the NET amount you think it will be in the field provided.
Do NOT include earned income tax credit payments you may have received. If you were not, and do
not expect to be self-employed, select None.
Have these wages or self-employment earnings decreased in the last two years?
We will be comparing the information you provided about your income and your spouse's income
with information from other Federal, State and local government agencies. Since some of that
information may be outdated, it will help us process your application if we know that the information
we receive from the other agencies is too high.
If the amount of the wages or self-employment income you listed in the questions above has
decreased in the last two calendar years, select Yes.
Have you or your spouse stopped working in 2006 or 2007, or plan to stop working in 2007
or 2008?
If you or your spouse stopped working this year or last year, or plan to stop this year or next year,
select Yes and enter the month and year in the fields provided.
Do you or your spouse have to pay for things related to a disability or blindness that
enable you to work?
We will only count part of your earnings toward the income limit if you:
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Help: Wages And Earnings
●
work;
●
receive Social Security benefits based on a disability or blindness; and
●
have work-related expenses for which you are not reimbursed.
If you have work-related expenses, select Yes. You will not need to tell us the amount of those
expenses. We will not count a percentage of your earnings. When we send you a letter that says
whether you are eligible for the extra help or not, we will also tell you how much of your earnings we
did not count. If you think the amount of work-related expenses we used was less than your actual
work-related expenses, you may contact us to tell us the actual amount of your expenses.
Close this window to return to the application.
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Help: Wages And Earnings
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Wages And Earnings
What do you expect to earn in wages before taxes and deductions this calendar year?
If you expect to earn money for any labor or services you provide on an hourly, daily, or piecework
basis during this calendar year, select Wages of: and enter the amount BEFORE taxes and
deductions you think you will earn in the field provided. If you did not, and do not expect to earn
wages, select None. Do NOT include earned income tax credit payments you may have received.
What do you expect your net earnings from self-employment to be this calendar year?
If you expect to have net earnings or a net loss from self-employment for this year, select the
appropriate response and enter the NET amount you think it will be in the field provided. Do NOT
include earned income tax credit payments you may have received. If you were not, and do not
expect to be self-employed, select None.
Have these wages or self-employment earnings decreased in the last two years?
We will be comparing the information you provided about your income with information from other
Federal, State and local government agencies. Since some of that information may be outdated, it
will help us process your application if we know that the information we receive from the other
agencies is too high.
If the amount of the wages or self-employment income you listed in the questions above has
decreased in the last two calendar years, select Yes.
Have you stopped working in 2006 or 2007, or plan to stop working in 2007 or 2008?
If you stopped working this year or last year, or plan to stop this year or next year, select Yes and
enter the month and year in the fields provided.
Do you have to pay for things related to a disability or blindness that enable you to work?
We will only count part of your earnings toward the income limit if you:
●
work;
●
receive Social Security benefits based on a disability or blindness; and
●
have work-related expenses for which you are not reimbursed.
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Help: Wages And Earnings
If you have work-related expenses, select Yes. You will not need to tell us the amount of those
expenses. We will not count a percentage of your earnings. When we send you a letter that says
whether you are eligible for the extra help or not, we will also tell you how much of your earnings we
did not count. If you think the amount of work-related expenses we used was less than your actual
work-related expenses, you may contact us to tell us the actual amount of your expenses.
Close this window to return to the application.
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Help: Income Other Than Wages
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Income Other Than Wages
Do you or your spouse receive Social Security benefits?
If you or your spouse currently receive benefits from Social Security, enter the total amount received each month in this field.
To find out what amount to enter, use the amount on your annual cost-of-living adjustment letter you receive from Social
Security (see sample below). This is the amount BEFORE the premium for Medicare Medical Insurance is deducted. Other
types of deductions could include voluntary Federal tax withholding, partial recovery of an overpayment, child support
payments, garnishment, etc. (This is NOT an all-inclusive list.)
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Help: Income Other Than Wages
Do you or your spouse receive Railroad Retirement income?
If you or your spouse currently receive benefits from the Railroad Retirement Board, enter the total amount received each
month in this field. To find out what amount to enter, use the amount on your annual cost-of-living adjustment letter you
receive from the Railroad Retirement Board. This is the amount BEFORE the premium for Medicare Medical Insurance
is deducted. Other types of deductions could include voluntary Federal tax withholding, partial recovery of an overpayment,
child support payments, garnishment, etc. (This is NOT an all-inclusive list.)
Do you or your spouse receive Veterans benefits?
If you or your spouse currently receive benefits from the Department of Veterans Affairs, enter the total amount received
each month in this field. To find out what amount to enter, use the amount on your annual cost-of-living adjustment letter
you receive from the Department of Veterans Affairs. This is the amount BEFORE any deductions have been made. Types
of deductions could include voluntary Federal tax withholding, partial recovery of an overpayment, child support
payments, garnishment, etc. (This is NOT an all-inclusive list.)
Do you or your spouse receive income from other pensions or annuities?
If you or your spouse currently receive income from a pension, enter the total amount received each month in this field. If
you receive money from an insurance company (annuity) on a regular basis (monthly, yearly, etc.), enter that amount in this
field as well. This includes immediate and deferred annuity payments, and is the amount BEFORE any deductions have
been made. Types of deductions could include voluntary Federal tax withholding, partial recovery of an overpayment,
child support payments, garnishment, etc. (This is NOT an all-inclusive list.)
The entry for this field must be shown in a MONTHLY format. If the pension or annuity is received other than monthly, convert
to a monthly amount before entering (e.g., if received weekly, multiply by 52 and divide by 12; if received bi-weekly, multiply
by 26 and divide by 12; if received yearly, divide by 12, etc.)
Do NOT include annuities from certificates of deposit, stocks, bonds, mutual funds, IRAs or any other investments.
Do you or your spouse receive other income not listed above, including alimony, net rental income,
workers' compensation, etc.?
Indicate whether you or your spouse receive income from any other source. 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.
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings bonds, mutual funds,
IRAs or any similar investments, or any other cash at home or anywhere else.)
Do NOT list wages and self-employment, interest income, public assistance, medical reimbursements, or foster care
payments here. Other examples of possible income sources that should NOT be counted are:
●
Food Stamps;
●
House repairs;
●
Help from an energy assistance program;
●
Help with medical bills, treatment and drugs;
●
Housing assistance;
●
Disaster assistance;
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Help: Income Other Than Wages
●
Meals on Wheels;
●
Contributions from food banks;
●
Soup kitchens;
●
Earned income tax credit payments;
●
Victim's compensation payments;
●
Scholarships and education grants;
●
Certain distributions received by an Alaska Native from an Alaska Native Regional and Village Corporation;
●
Land held in trust by the United States for an individual Indian or tribe;
●
Funds held in trust by the Secretary of the Interior for an Indian tribe and distributed per capita to members of the tribe;
●
Payments to members of specific Indian tribes as provided by Federal legislation; and
●
Up to $2,000 per year received by an Indian that is derived from individual interests in trust or restricted lands.
Has any of the income from these sources decreased in the last two years?
We will be comparing the information you provided about your income and your spouse's income with information from
other Federal, State and local government agencies. Since some of that information may be outdated, it will help us
process your application if we know that the information we receive from the other agencies is too high.
If the amount of the income you listed in the questions above has decreased in the last two calendar years, select Yes.
Close this window to return to the application.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/hlp009a.html (3 of 3) [9/10/2007 7:30:04 AM]
Help: Income Other Than Wages
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Income Other Than Wages
Do you receive Social Security benefits?
If you currently receive benefits from Social Security, enter the total amount received each month in this field. To find out
what amount to enter, use the amount on your annual cost-of-living adjustment letter you receive from Social Security
(see sample below). This is the amount BEFORE the premium for Medicare Medical Insurance is deducted. Other types
of deductions could include voluntary Federal tax withholding, partial recovery of an overpayment, child support
payments, garnishment, etc. (This is NOT an all-inclusive list.)
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Help: Income Other Than Wages
Do you receive Railroad Retirement income?
If you currently receive benefits from the Railroad Retirement Board, enter the total amount received each month in this field.
To find out what amount to enter, use the amount on your annual cost-of-living adjustment letter you receive from the
Railroad Retirement Board. This is the amount BEFORE the premium for Medicare Medical Insurance is deducted. Other
types of deductions could include voluntary Federal tax withholding, partial recovery of an overpayment, child support
payments, garnishment, etc. (This is NOT an all-inclusive list.)
Do you receive Veterans benefits?
If you currently receive benefits from the Department of Veterans Affairs, enter the total amount received each month in
this field. To find out what amount to enter, use the amount on your annual cost-of-living adjustment letter you receive from
the Department of Veterans Affairs. This is the amount BEFORE any deductions have been made. Types of deductions
could include voluntary Federal tax withholding, partial recovery of an overpayment, child support payments, garnishment,
etc. (This is NOT an all-inclusive list.)
Do you receive income from other pensions or annuities?
If you currently receive income from a pension, enter the total amount received each month in this field. If you receive
money from an insurance company (annuity) on a regular basis (monthly, yearly, etc.), enter that amount in this field as
well. This includes immediate and deferred annuity payments, and is the amount BEFORE any deductions have been
made. Types of deductions could include voluntary Federal tax withholding, partial recovery of an overpayment, child
support payments, garnishment, etc. (This is NOT an all-inclusive list.)
The entry for this field must be shown in a MONTHLY format. If the pension or annuity is received other than monthly, convert
to a monthly amount before entering (e.g., if received weekly, multiply by 52; if received bi-weekly, multiply by 26; if
received yearly, divide by 12, etc.)
Do NOT include annuities from certificates of deposit, stocks, bonds, mutual funds, IRAs or any other investments.
Do you receive other income not listed above, including alimony, net rental income, workers' compensation, etc.?
Indicate whether you receive income from any other source. 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.
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings bonds, mutual funds,
IRAs or any similar investments, or any other cash at home or anywhere else.)
Do NOT list wages and self-employment, interest income, public assistance, medical reimbursements, or foster care
payments here. Other examples of possible income sources that should NOT be counted are:
●
Food Stamps;
●
House repairs;
●
Help from an energy assistance program;
●
Help with medical bills, treatment and drugs;
●
Housing assistance;
●
Disaster assistance;
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Help: Income Other Than Wages
●
Meals on Wheels;
●
Contributions from food banks;
●
Soup kitchens;
●
Earned income tax credit payments;
●
Victim's compensation payments;
●
Scholarships and education grants;
●
Certain distributions received by an Alaska Native from an Alaska Native Regional and Village Corporation;
●
Land held in trust by the United States for an individual Indian or tribe;
●
Funds held in trust by the Secretary of the Interior for an Indian tribe and distributed per capita to members of the tribe;
●
Payments to members of specific Indian tribes as provided by Federal legislation; and
●
Up to $2,000 per year received by an Indian that is derived from individual interests in trust or restricted lands.
Has any of the income from these sources decreased in the last two years?
We will be comparing the information you provided about your income with information from other Federal, State and
local government agencies. Since some of that information may be outdated, it will help us process your application if we
know that the information we receive from the other agencies is too high.
If the amount of the income you listed in the questions above has decreased in the last two calendar years, select Yes.
Close this window to return to the application.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/hlp009b.html (3 of 3) [9/10/2007 7:30:04 AM]
Help: Resources
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Resources
Do you or your spouse have any of the following resources? If Yes, enter the combined
total for those items.
Combined total of all bank accounts (checking, savings and certificates of deposit)
Combined total of all stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts
or other similar investments
Any other cash at home or anywhere else
To be eligible for help with prescription drug plan costs, your and your spouse's resources must be
within certain limits. Your resources include bank accounts (checking, savings, and certificates of
deposit), stocks, bonds, savings bonds (including book entry securities*), Individual Retirement
Accounts (IRA), and any other cash at home or anywhere else.
You can look at your most recent statements from your bank or stock broker to find out how much is
in your account(s).
* Book Entry Securities - In addition to traditional U.S. Savings Bonds, individuals now may go to
the Treasury Department's Internet site and make online purchases of electronic savings bonds.
Electronic savings bonds are also called "book entry securities." With book entry securities, the
individual's investment is recorded electronically by the Treasury Department and a paper savings
bond is not issued. If you have book entry securities, they are counted as resources and should be
reported on this application.
Do NOT include cash if it is from a Social Security check or pension check that you cashed this
month. Also, do NOT include the home you live in, vehicle(s), personal possessions, burial plots
or irrevocable burial contracts. Other examples of resources that should NOT be counted are:
●
Resources you could not easily convert to cash, such as jewelry or home furnishings;
●
Property you need for self support that is used in a trade or business;
●
The cash value of your life insurance if the total face value of the policies you own is $1,500
or less;
●
The cash value of your spouse's life insurance if the total face value of the policies he or she
owns is $1,500 or less;
●
Irrevocable burial trusts;
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Help: Resources
●
Disaster assistance;
●
Certain distributions received by an Alaska Native from an Alaska Native Regional and
Village Corporation;
●
Land held in trust by the United States for an individual Indian or tribe;
●
Funds held in trust by the Secretary of the Interior for an Indian tribe and distributed per
capita to members of the tribe;
●
Payments to members of specific Indian tribes as provided by Federal legislation; and
●
Up to $2,000 per year received by an Indian that is derived from individual interests in trust
or restricted lands.
NOTE: Certain other money you may be holding is not counted for nine months, such as:
●
Retroactive Social Security or Supplemental Security Income benefits;
●
Tax advances and refunds related to earned income tax credits and child tax credits;
●
Compensation you receive as a crime victim;
●
Relocation assistance from a state or local government; and
●
Scholarships and education grants.
Do you or your spouse own life insurance policies with a total face value of more than
$1,500?
If you or your spouse own life insurance policies, find out their total face value. To find out how
much the face value of your policy is, refer to your policy package. For example, if you have a life
insurance policy that would pay out $20,000 if you or your spouse should pass away, select Yes.
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.
You do not have to turn in your life insurance policies to be eligible for the extra help. However, we
may need to know the value of your life insurance policies to decide if you meet the resource limit.
If the total face value of all your life insurance policies is $1,500 or less, we do not need to know
about them. Neither do we need to know about your spouse's policies if their total face value is not
more than $1,500. The face value of the policy is the amount the insurance company would pay if
you should pass away.
If the total face value of your policies is more than $1,500, we need to know how much the
insurance company would pay if you cashed in the policy. This is known as the cash value of the
policy.
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Help: Resources
To find out the cash value of your policies, look at each policy. If the policy says something like,
"This policy has no cash value," enter "0" in the field that asks for the value. If the policy has a cash
value, the policy may include a table that says what the value is based on and how many years you
have owned the policy. If so, enter the value shown in the table. If you have more than one policy,
enter the total value of all of the policies.
NOTE: Do NOT combine the cash values of your policies with those of your spouse's unless you
each have policies in your own name with a total face value of more than $1,500.
If your policies do not have a cash value table, contact your insurance agent or the insurance
company to find out the cash value of the policies.
If you cannot determine the cash value on your policies and cannot obtain it from your insurance
agent or company, you may use the following chart to estimate the cash value using the Face Value
and the number of years you owned the policy.
Chart for Estimating Cash Value
Years policy has been in effect
Estimated percentage of Face Value
20 or more
60%
15-19
50%
11-14
45%
6-10
30%
4-5
20%
3
10%
2
5%
1
0%
EXAMPLE: You own a 5-year-old policy with a Face Value of $2,000. Using the chart
above, the estimated Cash Value is $400 (i.e., 20% of $2,000).
If you are not comfortable estimating the cash value of your policies using this chart, you may call
Social Security toll-free at 1-800-772-1213 and we will help you determine the cash value.
Will some money from any of the sources listed above be used to pay for funeral or burial
expenses?
If you do not expect to use any of the money or investments that you listed on this page to pay for
your or your spouse's funeral or burial expenses, select No. If you do, skip to the next question (i.e.,
a Yes response is not necessary in this case, and there is no Yes response entry available for this
question).
Other than your home and the property on which it is located, do you or your spouse own
any real estate?
Select Yes if you or your spouse own real estate other than the home in which you live.
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Help: Resources
Examples of other real estate are summer homes, rental properties or undeveloped land you own.
Include real estate that you own with your spouse or with another person or persons. If Yes, a Social
Security representative will contact you to discuss this further.
Close this window to return to the application.
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Help: Resources
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Resources
Do you have any of the following resources? If Yes, enter the combined total for those
items.
Combined total of all bank accounts (checking, savings and certificates of deposit)
Combined total of all stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts
or other similar investments
Any other cash at home or anywhere else
To be eligible for help with prescription drug plan costs, your resources must be within certain limits.
Your resources include bank accounts (checking, savings, and certificates of deposit), stocks,
bonds, savings bonds (including book entry securities*), Individual Retirement Accounts (IRA), and
any other cash at home or anywhere else.
You can look at your most recent statements from your bank or stock broker to find out how much is
in your account(s).
* Book Entry Securities - In addition to traditional U.S. Savings Bonds, individuals now may go to
the Treasury Department's Internet site and make online purchases of electronic savings bonds.
Electronic savings bonds are also called "book entry securities." With book entry securities, the
individual's investment is recorded electronically by the Treasury Department and a paper savings
bond is not issued. If you have book entry securities, they are counted as resources and should be
reported on this application.
Do NOT include cash if it is from a Social Security check or pension check that you cashed this
month. Also, do NOT include the home you live in, vehicle(s), personal possessions, burial plots
or irrevocable burial contracts. Other examples of resources that should NOT be counted are:
●
Resources you could not easily convert to cash, such as jewelry or home furnishings;
●
Property you need for self support that is used in a trade or business;
●
The cash value of your life insurance if the total face value of the policies you own is $1,500
or less;
●
Irrevocable burial trusts;
●
Disaster assistance;
●
Certain distributions received by an Alaska Native from an Alaska Native Regional and
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Help: Resources
Village Corporation;
●
Land held in trust by the United States for an individual Indian or tribe;
●
Funds held in trust by the Secretary of the Interior for an Indian tribe and distributed per
capita to members of the tribe;
●
Payments to members of specific Indian tribes as provided by Federal legislation; and
●
Up to $2,000 per year received by an Indian that is derived from individual interests in trust
or restricted lands.
NOTE: Certain other money you may be holding is not counted for nine months, such as:
●
Retroactive Social Security or Supplemental Security Income benefits;
●
Tax advances and refunds related to earned income tax credits and child tax credits;
●
Compensation you receive as a crime victim;
●
Relocation assistance from a state or local government; and
●
Scholarships and education grants.
Do you own life insurance policies with a total face value of more than $1,500?
If you own life insurance policies, find out their total face value. To find out how much the face value
of your policy is, refer to your policy package. For example, if you have a life insurance policy that
would pay out $20,000 if you should pass away, select Yes.
If Yes, how much money would you get if you turned in your policies for cash right now?
This is NOT the face value of your policies. You may need to call your insurance company to help
answer this question.
You do not have to turn in your life insurance policies to be eligible for the extra help. However, we
may need to know the value of your life insurance policies to decide if you meet the resource limit.
If the total face value of all your life insurance policies is $1,500 or less, we do not need to know
about them. The face value of the policy is the amount the insurance company would pay if you
should pass away.
If the total face value of your policies is more than $1,500, we need to know how much the
insurance company would pay if you cashed in the policy. This is known as the cash value of the
policy.
To find out the cash value of your policies, look at each policy. If the policy says something like,
"This policy has no cash value," enter "0" in the field that asks for the value. If the policy has a cash
value, the policy may include a table that says what the value is based on and how many years you
have owned the policy. If so, enter the value shown in the table. If you have more than one policy,
enter the total value of all of the policies.
If your policies do not have a cash value table, contact your insurance agent or the insurance
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Help: Resources
company to find out the cash value of the policies.
If you cannot determine the cash value on your policies and cannot obtain it from your insurance
agent or company, you may use the following chart to estimate the cash value using the Face Value
and the number of years you owned the policy.
Chart for Estimating Cash Value
Years policy has been in effect
Estimated percentage of Face Value
20 or more
60%
15-19
50%
11-14
45%
6-10
30%
4-5
20%
3
10%
2
5%
1
0%
EXAMPLE: You own a 5-year-old policy with a Face Value of $2,000. Using the chart
above, the estimated Cash Value is $ 400 (i.e., 20% of $2,000).
If you are not comfortable estimating the cash value of your policies using this chart, you may call
Social Security toll-free at 1-800-772-1213 and we will help you determine the cash value.
Will some money from any of the sources listed above be used to pay for funeral or burial
expenses?
If you do not expect to use any of the money or investments that you listed on this page to pay for
your funeral or burial expenses, select No. If you do, skip to the next question (i.e., a Yes response
is not necessary in this case, and there is no Yes response entry available for this question).
Other than your home and the property on which it is located, do you own any real estate?
Select Yes if you own real estate other than the home in which you live. Examples of other real
estate are summer homes, rental properties or undeveloped land you own. Include real estate that
you own by yourself, or with another person or persons. If Yes, a Social Security representative will
contact you to discuss this further.
Close this window to return to the application.
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Help: Worked In 2006 or 2007
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Worked In 2006 or 2007
Have You Worked In 2006 or 2007?
When we determine whether you are eligible for help with prescription drug plan costs, we consider
the wages and self-employment net earnings that you (and your spouse, if married and living
together) receive.
If you (or your spouse, if married and living together) worked in 2006 or 2007, we will ask you about
your wages and self-employment earnings when you complete the application for this help.
If neither you nor your spouse worked in these years, we will not ask you about your wages and selfemployment earnings when you complete the application for this help.
If you worked in 2006 or 2007, select Yes.
Close this window to return to the application.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/hlp011a.html [9/10/2007 7:30:07 AM]
Help: Spouse Worked In 2006 or 2007
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Spouse Worked In 2006 or 2007
Has Your Spouse Worked In 2006 or 2007?
When we determine eligibility for help with prescription drug plan costs, we consider the wages and
self-employment net earnings that you and your spouse receive.
If you or your spouse worked in 2006 or 2007, we will ask you about your wages and selfemployment earnings when you complete the application for this help.
If neither you nor your spouse worked in these years, we will not ask you about your wages and selfemployment earnings when you complete the application for this help.
If your spouse worked in 2006 or 2007, select Yes.
Close this window to return to the application.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/hlp011b.html [9/10/2007 7:30:08 AM]
Help: Have You Worked In This Calendar Year
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Have You Worked In This Calendar Year
Have You Worked In This Calendar Year?
If you have worked at any time during the present calendar year, select Yes for this question. If you
have not worked at any time during the current calendar year, select No.
Close this window to return to the application.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/hlp012a.html [9/10/2007 7:30:08 AM]
Help: Has Your Spouse Worked In This Calendar Year
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Has Your Spouse Worked In This Calendar Year
Has Your Spouse Worked In This Calendar Year?
If your spouse has worked at any time during the present calendar year, select Yes for this question.
If your spouse has not worked at any time during the current calendar year, select No.
Close this window to return to the application.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/hlp012b.html [9/10/2007 7:30:09 AM]
Help: Under 65 Years Old
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Under 65 Years Old
Are You UNDER 65 Years Old?
If you are under age 65, blind or disabled and working, we may be able to exclude some of your
earnings when we determine your eligibility for help with prescription drug costs. If you spend part of
your earnings to pay for things needed in order to work, we will not count those earnings when we
determine eligibility. For example, we would exclude the amount spent on attendant care, certain
drugs, medical supplies and devices, certain types of training and therapy, certain work-related
equipment, etc.
Close this window to return to the application.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/hlp013a.html [9/10/2007 7:30:09 AM]
Help: Spouse Under 65 Years Old
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Spouse Under 65 Years Old
Is Your Spouse UNDER 65 Years Old?
If your spouse is under age 65, blind or disabled and working, we may be able to exclude some of
his or her earnings when we determine eligibility for help with prescription drug costs. If your spouse
spends part of his or her earnings to pay for things needed in order to work, we will not count those
earnings when we determine eligibility. For example, we would exclude the amount spent on
attendant care, certain drugs, medical supplies and devices, certain types of training and therapy,
certain work-related equipment, etc.
Close this window to return to the application.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/hlp013b.html [9/10/2007 7:30:10 AM]
Help: Ready To Submit
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Help: Ready To Submit
To The Best Of My Knowledge
This statement means that everything you have told us on the application is true and correct to the
best of your knowledge. We realize that some of the information we asked for can change from
one day to the next. We also realize that some of the amounts you entered are estimates. You will
not be penalized as long as you have given us your best estimates in those situations. However, if
you know that something you told us on the application is not correct, select Previous to go back
and correct the information.
If the information you told us on the application is true and correct to the best of your knowledge,
check the box next to your name and select Submit Now to finish this application.
Close this window to return to the application.
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Overview of Pages in i1020
Overview of Pages in i1020
These screenshots were generated on 8/23/2007 around 3:39 p.m.
Screen Number
Screen Name
Section: Entry and Exit
ee001
Welcome
ee001fe
Welcome
ee002
Should You Use This Application?
ee003
Welcome Back
ee004
Sign Out
ee005a
You Are Not Eligible For The Extra Help
ee005b
Go Ahead
ee006a
Preparing To Find Out If You Qualify
ee006b
Preparing To Use This Application
Section: MC pages
mc001a
About You And Your Spouse
mc001a_WITH
About You And Your Spouse
mc001b
About You
mc001c
About The Person Completing The Form And The People You
Are Helping
mc001d
About The Person Completing The Form And The Person You
Are Helping
mc002
Reentry Number Issued Normal Process
mc003a
About Your And Your Spouse's Living Situation - Married
mc003b
About Your Living Situation - Single
mc004a_WITHOUT
Wages And Earnings - Married
mc004a_WITH
Wages And Earnings - Married
mc004b_WITHOUT
Wages And Earnings - Single
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Overview of Pages in i1020
mc004b_WITH
Wages And Earnings - Single
mc005a
Income Other Than Wages And Earnings - Married
mc005b
Income Other Than Wages And Earnings - Single
mc006a
Resources - Married
mc006b
Resources - Single
mc007a
Tool: Add Up Your Accounts
mc007b
Tool: Add Up Your Investments
mc007c
Tool: Add Up Your Other Pensions And Annuities
mc007d
Tool: Add Up Your Types Of Income
Section: Qualifier pages
qu001a_WITHOUT
Find Out If You And Your Spouse Qualify: Part 1 - Married
qu001a_WITH
Find Out If You And Your Spouse Qualify: Part 1 - Married
qu001b
Find Out If You Qualify: Part 1 - Single
qu002a_WITH
Find Out If You And Your Spouse Qualify: Part 3 - Married
qu002b_WITHOUT
Find Out If You Qualify: Part 3 - Single
qu002b_WITH
Find Out If You Qualify: Part 3 - Single
qu003a
Find Out If You Qualify: Part 2 Of 3
qu003b
Find Out If You Qualify: Part 2 Of 3
qu004a
Find Out If You Qualify: Results - You Should Apply
qu004b
Find Out If You Qualify: Results - You Probably Do Not Qualify
Section: Review and Send
rs001
Review Your Information
rs001_MISSING_DATA
Review Your Information
rs003_NO_SINGLE
Ready To Submit
rs003_YES_SINGLE
Ready To Submit
rs003_NO_MARRIED_BOTH
Ready To Submit
rs003_NO_MARRIED_SELF
Ready To Submit
rs003_YES_MARRIED
Ready To Submit
rs004_NO_SINGLE
Successful Submission - Print Or Save Your Receipt
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Overview of Pages in i1020
rs004_NO_MARRIED_BOTH
Successful Submission - Print Or Save Your Receipt
rs004_NOT_SUBMITTED
Unsuccessful Submission
rs005
Next Steps
rs006
Missing Information (Fix Errors)
rs007_NO_SINGLE
Successful Submission - Print Or Save Your Receipt
rs007_NO_MARRIED_BOTH
Successful Submission - Print Or Save Your Receipt
rs007_NOT_SUBMITTED
Unsuccessful Submission
Section: Help pages
hlp001
Main Help Page
hlp002
Help: Should You Use This Application
hlp003a
Help: Find Out If You And Your Spouse Qualify: Part 1
hlp003b
Help: Find Out If You Qualify: Part 1
hlp004a
Help: Find Out If You And Your Spouse Qualify: Part 3
hlp004b
Help: Find Out If You Qualify: Part 3
hlp005a
Help: Find Out If You and Your Spouse Qualify: Part 2
hlp005b
Help: Find Out If You Qualify: Part 2
hlp006a
Help: About You And Your Spouse
hlp006b
Help: About You
hlp006c
Help: About The Person Completing This Form And The People
You Are Helping
hlp006d
Help: About The Person Completing This Form And The Person
You Are Helping
hlp007a
Help: About Your And Your Spouse's Living Situation
hlp007b
Help: About Your Living Situation
hlp008a
Help: Wages And Earnings
hlp008b
Help: Wages And Earnings
hlp009a
Help: Income Other Than Wages
hlp009b
Help: Income Other Than Wages
hlp010a
Help: Resources
hlp010b
Help: Resources
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Overview of Pages in i1020
hlp011a
Help: Worked In 2006 or 2007
hlp011b
Help: Spouse Worked In 2006 or 2007
hlp012a
Help: Have You Worked In This Calendar Year
hlp012b
Help: Has Your Spouse Worked In This Calendar Year
hlp013a
Help: Under 65 Years Old
hlp013b
Help: Spouse Under 65 Years Old
hlp014
Help: Ready To Submit
Section: Message pages
msg105
Authentication - Medicare Part D Database Not Eligible Or SSI
Recipient
msg016_MARRIED
Check The Social Security Number You Entered
msg016_SINGLE
Check The Social Security Number You Entered
msg023
How The Online Application Works
msg004
Internet Security Policy
msg031
Limit Number Of Restarts
msg029
Limit Number Of Starts For A New Application
msg034
Limit On The Number Of Tries To Start An Application
msg104
Name Check Mismatch
msg102
Not Eligible For The Prescription Drug Plan
msg028
Off Hours Message
msg061
Other Ways To Apply
msg015
Paperwork Reduction Act Statement
msg047_WORKED_2Y
Please Confirm
msg047_WORKED_2Y_SPOUSE Please Confirm
msg047_WORKED_1Y
Please Confirm
msg047_WORKED_1Y_SPOUSE Please Confirm
msg047_65_SELF
Please Confirm
msg047_65_SPOUSE
Please Confirm
msg063
Print/Save/View Guide
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Overview of Pages in i1020
msg030
Processing Alert
msg017
Sign-In Problem
msg024
Special Instructions For Blind Users
msg027
System Failure
msg018
There Is A Pending Application For This Social Security Number
msg045
Warning System Shutdown
msg026
We Cannot Process Your Request
msg106
What You Will Need
msg008
You Do Not Live In One Of The 50 States Or DC
msg019
You Have Already Sent Us An Application
msg025
Your Session Has Expired
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About You And Your Spouse
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Complete
Application
Review
Submit
Print
Receipt
About You And Your Spouse
We need some basic information about how to contact you and your spouse in case we have any questions about
this application. Once you complete all the information on this page, we will provide you with a reentry number
and you will be able to exit the application and return to complete it later.
About You
Your Name: More Info
(First, Middle Initial, Last, Suffix)
Enter your name as it appears on your most recent Social Security
card.
Your Social Security Number: More
Info
(Do NOT include dashes or hyphens.)
What is your date of birth? More
Info
Month
Day
Year
Have you worked in 2006 or 2007? More
Info
No
Yes
About Your Spouse
Spouse's Name: More Info
(First, Middle Initial, Last, Suffix)
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About You And Your Spouse
Enter your spouse’s name as it appears on his or her most recent Social Security
card.
Spouse's Social Security Number: More
Info
(Do NOT include dashes or hyphens.)
What is your spouse's date of birth? More
Info
Month
Day
Year
Has your spouse worked in 2006 or 2007? More
Info
No
Yes
Contact Information
Your Mailing Address: More
Info
We have changed our address within the last three
months
(Address Line
1)
Apt. No.
(Address Line
2)
(Address Line
3)
(City, State,
ZIP)
Your Phone Number: More
Info
(
)
-
Other Information
If your spouse has Medicare (or expects to have it in the next three months), does he or she also wish to
apply? More Info
No
Yes
Do you have combined savings, investments, and real estate worth more than $23,410? More Info
Include the things you own by yourself, with your spouse or with another person. DO NOT include the home
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About You And Your Spouse
you live in, vehicles, personal possessions, burial plots or irrevocable burial contracts.
No
Sure
Yes
Not
OPTIONAL: If you want us to contact someone else if we have additional questions, please provide the
person's name and a daytime phone number. More Info
Contact Person's
Name:
(First, Last)
Contact's Phone Number: More
Info
(
)
-
Continue
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About You And Your Spouse
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Complete
Application
Review
Submit
Print
Receipt
About You And Your Spouse
We need some basic information about how to contact you and your spouse in case we have any questions about
this application. Once you complete all the information on this page, we will provide you with a reentry number
and you will be able to exit the application and return to complete it later.
About You
Your Name: More Info
John
Doe
(First, Middle Initial, Last, Suffix)
Enter your name as it appears on your most recent Social Security
card.
Your Social Security Number: More
Info
743993047
(Do NOT include dashes or hyphens.)
What is your date of birth? More
Info
January 01
1960
Have you worked in 2006 or 2007? More
Info
Change This Answer
No
Yes
About Your Spouse
Spouse's Name: More Info
(First, Middle Initial, Last, Suffix)
Jane
Doe
Enter your spouse’s name as it appears on his or her most recent Social Security
card.
Spouse's Social Security Number: More 743991047
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About You And Your Spouse
Info
(Do NOT include dashes or hyphens.)
What is your spouse's date of birth? More February 02
1901
Info
Has your spouse worked in 2006 or 2007? More
Info
Change This Answer
No
Yes
Contact Information
Your Mailing Address: More
Info
We have changed our address within the last three
months
(Address Line 123 Main Street
1)
Apt. No.
(Address Line
2)
(Address Line
3)
(City, State, Anywhere
ZIP)
34567
Your Phone Number: More
Info
SC
( 540 ) 555 9876
Other Information
If your spouse has Medicare (or expects to have it in the next three months), does he or she also wish to
apply? More Info
No
Yes
Do you have combined savings, investments, and real estate worth more than $23,410? More Info
Include the things you own by yourself, with your spouse or with another person. DO NOT include the home
you live in, vehicles, personal possessions, burial plots or irrevocable burial contracts.
No
Sure
Yes
Not
OPTIONAL: If you want us to contact someone else if we have additional questions, please provide the
person's name and a daytime phone number. More Info
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About You And Your Spouse
Contact Person's
Name:
(First, Last)
Contact's Phone Number: More
Info
(
)
-
Done
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About You
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Complete
Application
Review
Submit
Print
Receipt
About You
We need some basic information about how to contact you in case we have any questions about this
application. Once you complete all the information on this page, we will provide you with a reentry number
and you will be able to exit the application and return to complete it later.
Your Name: More Info
(First, Middle Initial, Last, Suffix)
Enter your name as it appears on your most recent Social Security
card.
Your Social Security Number: More
Info
(Do NOT include dashes or hyphens.)
What is your date of birth: More
Info
Month
Day
Year
Have you worked in 2006 or 2007? More
Info
No
Yes
Contact Information
Your Mailing Address: More
Info
I have changed my address within the last three
months
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About You
(Address Line
1)
Apt. No.
(Address Line
2)
(Address Line
3)
(City, State,
ZIP)
Your Phone Number: More
Info
(
)
-
Other Information
OPTIONAL: If you want us to contact someone else if we have additional questions, please provide
the person's name and a daytime phone number. More Info
Contact Person's
Name:
(First, Last)
Contact's Phone Number: More
Info
(
)
-
Do you have combined savings, investments, and real estate worth more than $11,710? More Info
Include the things you own by yourself or with another person. DO NOT include the home you live in,
vehicles, personal possessions, burial plots or irrevocable burial contracts.
No
Sure
Yes
Not
Continue
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About The Person Completing The Form And The People You Are Helping
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Complete
Application
Review
Submit
Print
Receipt
About The Person Completing The Form And The People You Are Helping
We need some basic information about how to contact you and the people you are helping in case we have any
questions about this application. Once you complete all the information on this page, we will provide you with a
reentry number and you will be able to exit the application and return to complete it later.
About The Person Completing The Form
Form Completer's
Name:
(First, Middle Initial, Last)
Relationship to Applicant: More
Info
If other, please indicate:
Form Completer's Phone Number: More
(
Info
)
-
Form Completer's Address: More
Info
(Address Line
1)
Apt. No.
(Address Line
2)
(Address Line
3)
(City, State,
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About The Person Completing The Form And The People You Are Helping
ZIP)
About The Person You Are Helping
Primary Applicant's Name: More Info
(First, Middle Initial, Last, Suffix)
Enter the name as it appears on the primary applicant’s most recent Social Security
card.
Primary Applicant's Social Security Number: More
Info
(Do NOT include dashes or hyphens.)
What is the primary applicant's date of birth? More
Info
Month
Day
Year
Has the primary applicant worked in 2006 or 2007? More
Info
No
Yes
If the spouse has Medicare (or expects to have it in the next three months), does he or she also wish to
apply? More Info
No
Yes
Do the applicants have combined savings, investments, and real estate worth more than $23,410? More
Info
Include the things owned by the primary applicant separately, jointly with his or her spouse, or with another
person. DO NOT include the home they live in, vehicles, personal possessions, burial plots or
irrevocable burial contracts.
No
Sure
Yes
Not
About The Applicant's Spouse
Spouse's Name: More Info
(First, Middle Initial, Last, Suffix)
Enter the spouse’s name as it appears on his or her most recent Social Security
card.
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About The Person Completing The Form And The People You Are Helping
Spouse's Social Security Number: More
Info
(Do NOT include dashes or hyphens.)
What is the spouse's date of birth? More
Info
Month
Day
Year
Has the applicant's spouse worked in 2006 or 2007? More
Info
No
Yes
Applicant's Contact Information
Mailing Address: More
Info
The applicant has changed his/her address within the last three
months
(Address Line
1)
Apt. No.
(Address Line
2)
(Address Line
3)
(City, State,
ZIP)
Phone Number: More
Info
(
)
-
Other Information
OPTIONAL: If you want us to contact someone else if we have additional questions, please provide the
person's name and a daytime phone number. More Info
Contact Person's
Name:
(First, Last)
Contact's Phone Number: More
Info
(
)
-
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About The Person Completing The Form And The People You Are Helping
Continue
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About The Person Completing The Form And The Person You Are Helping
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Complete
Application
Review
Submit
Print
Receipt
About The Person Completing The Form And The Person You Are Helping
We need some basic information about how to contact you and the person you are helping in case we have
any questions about this application. Once you complete all the information on this page, we will provide you
with a reentry number and you will be able to exit the application and return to complete it later.
About The Person Completing The Form
Form Completer's
Name:
(First, Middle Initial, Last)
Relationship to Applicant: More
Info
If other, please indicate:
Form Completer's Phone Number: More
(
Info
)
-
Form Completer's Address: More
Info
(Address Line
1)
Apt. No.
(Address Line
2)
(Address Line
3)
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About The Person Completing The Form And The Person You Are Helping
(City, State,
ZIP)
About The Person You Are Helping
Applicant's Name: More Info
(First, Middle Initial, Last, Suffix)
Enter the name as it appears on the applicant's most recent Social Security
card.
Applicant's Social Security Number: More
Info
(Do NOT include dashes or hyphens.)
What is the applicant's date of birth? More
Info
Month
Day
Year
Has the applicant worked in 2006 or 2007? More
Info
No
Yes
Applicant's Contact Information
Mailing Address: More
Info
The applicant has changed his/her address within the last three
months
(Address Line
1)
Apt. No.
(Address Line
2)
(Address Line
3)
(City, State,
ZIP)
Phone Number: More
Info
(
)
-
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About The Person Completing The Form And The Person You Are Helping
Other Information
OPTIONAL: If you want us to contact someone else if we have additional questions, please provide the
person's name and a daytime phone number. More Info
Contact Person's
Name:
(First, Last)
Contact's Phone Number: More
Info
(
)
-
Does the applicant have combined savings, investments, and real estate worth more than $11,710?
More Info
Include the things the applicant owns separately or with another person. DO NOT include the home he or
she lives in, vehicles, personal possessions, burial plots or irrevocable burial contracts.
No
Sure
Yes
Not
Continue
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Reentry Number Issued Normal Process
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
Complete
Application
Need Help?
Review
Submit
Print
Receipt
Print The Reentry Number
Before going any further, we are giving you a Reentry Number. If you get disconnected, or if you
decide to continue the application later, you will need this number. It will let you come back to the
application and continue where you left off without losing any information you already entered.
Applicant's Social Security Number:
743997047
Reentry Number: 49952662
Print or save this page so you will have a copy of your Reentry Number. To print this page, please
use the Print button at the top of your browser.
If you lose or forget your Reentry Number, you will have to begin this application again, and you will
lose all the information you already entered. You can start a new application up to three times.
Social Security can help you start the process again, but we cannot look up the Reentry Number for
you.
To Come Back To This Application:
1. Go to this website: http://www.socialsecurity.gov/prescriptionhelp; and
2. Type in the Social Security and Reentry Numbers shown above.
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Reentry Number Issued Normal Process
Last Date To Complete This Application
You need to complete an application by October 22, 2007; otherwise you may lose benefits.
Important Information
You might have received a notice from us advising you of an earlier time period for filing the
application. If you did, it was because you or someone on your behalf contacted us about filing
before you started the Internet application. Generally, it is to your advantage to file within that earlier
period to receive the earliest filing date.
Continue
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About Your And Your Spouse's Living Situation - Married
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
Complete
Application
Need Help?
Review
Submit
Print
Receipt
About Your And Your Spouse's Living Situation
Not counting your spouse, how many other relatives live in your household and receive at least one-half of
their financial support from you or your spouse? Do NOT include yourself or your spouse in the number
you enter. If your household consists only of you and your spouse, enter "0." More Info
We ask this because your household size may affect the amount of help you can get. We count relatives related to
you by blood, marriage or adoption.
Do you count on anyone to help pay for any of the following household expenses?
More Info
No
Yes, they provide: $
per month
(If the amount changes from month to month or you do not receive it every month, enter the average monthly amount
for the past year.)
●
Food
●
Mortgage
●
Rent
●
Heating
Fuel or Gas
●
Electricity
and Water
●
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.
Previous
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Continue
About Your Living Situation - Single
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
Complete
Application
Need Help?
Review
Submit
Print
Receipt
About Your Living Situation
How many relatives live in your household and receive at least one-half of their financial support from
you? Do NOT include yourself in the number you enter. If your household consists only of you enter "0."
More Info
We ask this because your household size may affect the amount of help you can get. We count relatives related to
you by blood, marriage or adoption.
Do you count on anyone to help pay for any of the following household expenses?
More Info
No
Yes, they provide: $
per month
(If the amount changes from month to month or you do not receive it every month, enter the average monthly amount
for the past year.)
●
Food
●
Mortgage
●
Rent
●
Heating
Fuel or Gas
●
Electricity
and Water
●
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.
Previous
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Continue
Wages And Earnings - Married
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
Complete
Application
Need Help?
Review
Submit
Print
Receipt
Wages And Earnings
To qualify for help with your prescription drug costs, we need to know your and your spouse's
combined income, including wages and self-employment income. However, if your spouse lives at a
different address permanently, like a nursing home, we do not count your spouse's income when we
determine your eligibility for extra help.
You told us that you worked in 2006 or 2007. If this is not correct, please
Change This Answer
You told us that your spouse worked in 2006 or 2007. If this is not correct, please
Change This Answer
What do you or your spouse expect to earn in wages before taxes and deductions this
calendar year? More Info
You
None
year
Spouse
None
year
Wages of:, $
this
Wages of:, $
this
What do you or your spouse expect your net earnings from self-employment to be this
calendar year? More Info
You
None
Net EARNINGS of: $
year
this
Net LOSS
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Wages And Earnings - Married
Spouse
None
Net EARNINGS of: $
year
this
Net LOSS
Have these wages or self-employment earnings decreased in the last two years?
More Info
No
Yes
Have you or your spouse stopped working in 2006 or 2007, or plan to stop working in 2007 or
2008? More Info
You
Yes, stopped/plan to stop: Month
No
Year
Spouse
No
Yes, stopped/plan to stop: Month
Year
Do you or your spouse have to pay for things related to a disability or blindness that enable
you to work? More Info
We will count only a part of your earnings towards 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
modification, driver assistance, or other special work-related transportation needs; work-related
assistive technology; guide dog expenses; sensory and visual aids; and Braille translations.
YouNot Applicable for
You
Spouse
No
Yes
Previous
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Wages And Earnings - Married
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
Complete
Application
Need Help?
Review
Submit
Print
Receipt
Wages And Earnings
To qualify for help with your prescription drug costs, we need to know your and your spouse's
combined income, including wages and self-employment income. However, if your spouse lives at a
different address permanently, like a nursing home, we do not count your spouse's income when we
determine your eligibility for extra help.
You told us that you worked in 2006 or 2007. If this is not correct, please
Change This Answer
You told us that your spouse did not work in 2006 or 2007. If this is not correct, please
Change This Answer
What do you or your spouse expect to earn in wages before taxes and deductions this
calendar year? More Info
You
None
year
Wages of:, $
this
SpouseNot Applicable for Your
Spouse
What do you or your spouse expect your net earnings from self-employment to be this
calendar year? More Info
You
None
Net EARNINGS of: $
year
this
Net LOSS
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Wages And Earnings - Married
SpouseNot Applicable for Your
Spouse
Have these wages or self-employment earnings decreased in the last two years?
More Info
No
Yes
Have you or your spouse stopped working in 2006 or 2007, or plan to stop working in 2007 or
2008? More Info
You
No
Yes, stopped/plan to stop: Month
Year
SpouseNot Applicable for Your
Spouse
Previous
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Wages And Earnings - Single
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
Need Help?
Complete
Application
Review
Submit
Print
Receipt
Wages And Earnings
To qualify for help with your prescription drug costs, we need to know your income, including wages and selfemployment income.
You told us that you worked in 2006 or 2007. If this is not correct, please
Change This Answer
What do you expect to earn in wages before taxes and deductions this calendar year?
More Info
None
year
Wages of: $
this
What do you expect your net earnings from self-employment to be this calendar year?
More Info
None
Net EARNINGS of: $
year
this
Net LOSS
Have these wages or self-employment earnings decreased in the last two years?
More Info
No
Yes
Have you stopped working in 2006 or 2007, or plan to stop working in 2007 or 2008?
More Info
No
Yes, stopped/plan to stop: Month
Year
Do you have to pay for things related to a disability or blindness that enable you to work? More Info
We will count only a part of your earnings towards 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 modification, driver assistance, or other special work-related
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Wages And Earnings - Single
transportation needs; work-related assistive technology; guide dog expenses; sensory and visual aids; and Braille
translations.
No
Yes
Previous
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Wages And Earnings - Single
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
Need Help?
Complete
Application
Review
Submit
Print
Receipt
Wages And Earnings
To qualify for help with your prescription drug costs, we need to know your income, including wages
and self-employment income.
You told us that you worked in 2006 or 2007. If this is not correct, please
Change This Answer
What do you expect to earn in wages before taxes and deductions this calendar year?
More Info
None
year
Wages of: $ 1500
this
What do you expect your net earnings from self-employment to be this calendar year?
More Info
None
Net EARNINGS of: $
year
this
Net LOSS
Have these wages or self-employment earnings decreased in the last two years?
More Info
No
Yes
Have you stopped working in 2006 or 2007, or plan to stop working in 2007 or 2008?
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Wages And Earnings - Single
More Info
No
Yes, stopped/plan to stop: February
2007
Previous
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Income Other Than Wages And Earnings - Married
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
Complete
Application
Need Help?
Review
Submit
Print
Receipt
Income Other Than Wages And Earnings
If you or your spouse 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 fields.
Do NOT list wages and self-employment, interest income, public assistance, medical reimbursements
or foster care payments here. If you do not receive income from a source listed below, select No for
that source.
If you need help adding your pensions or annuities, select Add Pensions Or Annuities. If you need
help adding your other income, select Add Other Income. The total dollar amount calculated will
appear in the dollar amount field on this page when Add And Use Total is selected on the page
calculating the totals.
Do you or your spouse receive Social Security benefits? More Info
You
Yes, $
No
per month (before
deductions)
Spouse
Yes, $
No
per month (before
deductions)
Do you or your spouse receive Railroad Retirement income? More Info
You
No
Yes, $
per month (before
deductions)
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Income Other Than Wages And Earnings - Married
Spouse
Yes, $
No
per month (before
deductions)
Do you or your spouse receive Veterans benefits? More Info
You
Yes, $
No
per month (before
deductions)
Spouse
No
Yes, $
per month (before
deductions)
Do you or your spouse receive income from other pensions or annuities? More Info
(Do NOT include include annuities from certificates of deposit, stocks, bonds, mutual funds, IRAs or
any other investments.)
You
No
Yes, $
per month (before deductions)
Add Pensions Or Annuities
Spouse
No
Yes, $
per month (before deductions)
Add Pensions Or Annuities
Do you or your spouse receive other income not listed above, including alimony, net rental
income, workers' compensation, etc.? More Info
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings
bonds, mutual funds, IRAs or any similar investments, or any cash at home or anywhere else.)
You
No
Yes
If Yes, specify monthly amount and type(s):
Amount: $
per month
Add Other Income
Type:
Spouse
No
Yes
If Yes, specify monthly amount and type(s):
Amount: $
per month
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Income Other Than Wages And Earnings - Married
Add Other Income
Type:
Has any of the income from these sources decreased in the last two years?
More Info
No
Yes
Previous
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Income Other Than Wages And Earnings - Single
Skip Navigation Bar
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Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
Need Help?
Complete
Application
Review
Submit
Print
Receipt
Income Other Than Wages And Earnings
If you 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 fields.
Do NOT list wages and self-employment, interest income, public assistance, medical reimbursements or
foster care payments here. If you do not receive income from a source listed below, select No for that
source.
If you need help adding your pensions or annuities, select Add Pensions Or Annuities. If you need help
adding your other income, select Add Other Income. The total dollar amount calculated will appear in the
dollar amount field on this page when Add And Use Total is selected on the page calculating the totals.
Do you receive Social Security benefits? More
Info
No
Yes, $
per month (before
deductions)
Do you receive Railroad Retirement income? More
Info
No
Yes, $
per month (before
deductions)
Do you receive Veterans benefits? More
Info
No
Yes, $
per month (before
deductions)
Do you receive income from other pensions or annuities? More Info
(Do NOT include include annuities from certificates of deposit, stocks, bonds, mutual funds, IRAs or any other
investments.)
No
Yes, $
per month (before deductions)
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Income Other Than Wages And Earnings - Single
Add Pensions Or Annuities
Do you receive other income not listed above, including alimony, net rental income, workers'
compensation, etc.? More Info
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings bonds, mutual
funds, IRAs or any similar investments, or any cash at home or anywhere else.)
No
Yes
If Yes, specify monthly amount and type(s):
Amount: $
per month
Add Other Income
Type:
Has any of the income from these sources decreased in the last two years?
More Info
No
Yes
Previous
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Continue
Resources - Married
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
Complete
Application
Need Help?
Review
Submit
Print
Receipt
Resources
Please enter the money amounts of all bank accounts, investments or cash that either you, your spouse, or both of
you own. Include items that either of you own with another person.
If you need help adding your bank accounts, select Add Accounts. If you need help adding your investments, select
Add Investments. The total dollar amount calculated will appear in the dollar amount field on this page when Add And
Use Total is selected on the page calculating the totals.
Do you or your spouse have any of the following resources? If Yes, enter the combined total for those items.
More Info
Combined total of all bank accounts (checking, savings and certificates of
deposit)
No
Yes, we have: $
Add Accounts
Combined total of all stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts
or other similar investments
No
Yes, we have: $
Add Investments
Any other cash at home or anywhere
else
No
Yes, we have: $
Do you or your spouse own life insurance policies with a total face value of more than $1,500? More Info
You
No
Yes
Spouse
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Resources - Married
No
Yes
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.
$
Will some money from any of the sources listed above be used to pay for funeral or burial expenses? More
Info
This includes any bank accounts, investments, cash, and life insurance policies that you listed.
If Yes, skip to the next question. If no, select No and then go to the next question.
You
No
Spouse
No
Other than your home and the property on which it is located, do you or your spouse own any real estate?
More Info
Examples of other real estate are summer homes, rental properties or undeveloped land you own.
No
Yes
Previous
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Continue
Resources - Single
Skip Navigation Bar
Help With Medicare Prescription Drug Plan
Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
Complete
Application
Need Help?
Review
Submit
Print
Receipt
Resources
Please enter the money amounts of all bank accounts, investments or cash that you own. Include items that you own
with another person.
If you need help adding your bank accounts, select Add Accounts. If you need help adding your investments, select
Add Investments. The total dollar amount calculated will appear in the dollar amount field on this page when Add And
Use Total is selected on the page calculating the totals.
Do you have any of the following resources? If Yes, enter the combined total for those items. More Info
Combined total of all bank accounts (checking, savings and certificates of
deposit)
No
Yes, I have: $
Add Accounts
Combined total of all stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts
or other similar investments
No
Yes, I have: $
Add Investments
Any other cash at home or anywhere
else
No
Yes, I have: $
Do you own life insurance policies with a total face value of more than $1,500?
More Info
No
Yes
If Yes, how much money would you get if you turned in your insurance policies for cash right now? Enter the
amount.
This is not the face value of your policies. You may need to call your insurance company to help answer this question.
$
Will some money from any of the sources listed above be used to pay for funeral or burial expenses?
More Info
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No
Resources - Single
This includes any bank accounts, investments, cash, and life insurance policies that you listed.
If Yes, skip to the next question. If no, select No and then go to the next question.
Other than your home and the property on which it is located, do you own any real estate?
More Info
No
Yes
Examples of other real estate are summer homes, rental properties or undeveloped land you own.
Previous
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Continue
Tool: Add Up Your Accounts
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Complete
Application
Review
Submit
Print
Receipt
Tool: Add Up Your Accounts
We have provided a tool to help you accurately calculate the total value of your bank accounts.
Enter the appropriate amounts and we will calculate it for you.
Note: Once you leave this page, this tool will not save the individual amounts.
Bank Accounts: Checking Accounts
Checking Account $
1
Checking Account $
2
Checking Account $
3
Checking Account $
4
Bank Accounts: Savings Accounts
Savings Account $
1
Savings Account $
2
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Tool: Add Up Your Accounts
Savings Account $
3
Savings Account $
4
Bank Accounts: Certificates of Deposit (CD)
Certificate of Deposit $
Account 1
Certificate of Deposit $
Account 2
Certificate of Deposit $
Account 3
Certificate of Deposit $
Account 4
Cancel
Add And Use Total
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Tool: Add Up Your Investments
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Complete
Application
Review
Submit
Print
Receipt
Tool: Add Up Your Investments
We have provided a tool to help you accurately calculate the total value of your investments. Enter
the appropriate amounts and we will calculate it for you.
Note: Once you leave this page, this tool will not save the individual amounts.
Investments: Stocks, Bonds, Savings Bonds, Mutual Funds, Individual Retirement
Accounts (IRAs)
Investment Type $
1
Investment Type $
2
Investment Type $
3
Investment Type $
4
Investment Type $
5
Investment Type $
6
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Tool: Add Up Your Investments
Investment Type $
7
Investment Type $
8
Cancel
Add And Use Total
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Tool: Add Up Your Other Pensions And Annuities
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Complete
Application
Review
Submit
Print
Receipt
Tool: Add Up Your Other Pensions And Annuities
We have provided a tool to help you accurately calculate the total value of your pensions and
annuities. Enter the appropriate amounts and we will calculate it for you.
Note: Once you leave this page, this tool will not save the individual amounts.
You said that your other pensions and annuities total: $500
If you use the amounts you enter here, the new total will replace your previous answer.
Other Pensions and Annuities
Pension or Annuity $
Type 1
Pension or Annuity $
Type 2
Pension or Annuity $
Type 3
Pension or Annuity $
Type 4
Pension or Annuity $
Type 5
Pension or Annuity $
Type 6
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Tool: Add Up Your Other Pensions And Annuities
Pension or Annuity $
Type 7
Pension or Annuity $
Type 8
Cancel
Add And Use Total
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Tool: Add Up Your Types Of Income
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Complete
Application
Review
Submit
Print
Receipt
Tool: Add Up Your Types Of Income
We have provided a tool to help you accurately calculate the total value of your other types of
income. Enter the appropriate amounts and we will calculate it for you.
Note: Once you leave this page, this tool will not save the individual amounts.
You said that your other income totals: $500
If you use the amounts you enter here, the new total will replace your previous answer.
Other Types of Income (including alimony, net rental income, workers' compensation,
etc.)
Other Income Type $
1
Other Income Type $
2
Other Income Type $
3
Other Income Type $
4
Other Income Type $
5
Other Income Type $
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Tool: Add Up Your Types Of Income
6
Other Income Type $
7
Other Income Type $
8
Cancel
Add And Use Total
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Internet Security Policy
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Internet Security Policy
Is it safe to apply for Social Security Benefits over the Internet?
Social Security is taking all reasonable and proper measures, including encryption, to ensure that
your personal information is disclosed only to you. However, the Internet is an open system and
there is no absolute guarantee that others will not intercept the personal information you have
entered or requested and decrypted. Although this possibility is remote, it does exist.
What is encryption?
Encryption means that all information relating to you and your account is scrambled and locked with
a mathematical key during the electronic transfer. Most browsers have an icon such as a key or a
lock to represent an encrypted mode or session. A broken key, open lock, or no lock indicates that
the session or mode is not encrypted.
Why is special software necessary to access the Internet application?
So that your online request can remain confidential, Social Security uses a security protocol
(method) called Secure Sockets Layer (SSL) for this application. You must use a Web browser that
supports SSL. Netscape Navigator and Microsoft Internet Explorer are two browsers that support
SSL. Using this security protocol, all information sent between your computer and our server is
encrypted before being sent on the Internet.
Why SSL?
SSL provides a high level of security and is the security protocol supported by more browsers than
any other. It is estimated that about 92% of Web browsers have an SSL browser available for their
use.
We have found that a number of business, government, and educational networks do not have their
firewalls configured to allow passage of secure Web traffic. Check with your systems administrator
to determine if this is the case at your site. If this is the case you will not be able to access this
application web site.
Close this window to return to the application.
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You Do Not Live In One Of The 50 States Or DC
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
You Do Not Live In One Of The 50 States Or DC
People who live outside of the 50 states and the District of Columbia are not eligible for this help.
For more information, visit www.medicare.gov.
To contact Social Security, visit our Service Around the World web page.
Select Exit to leave this application. You will be taken to the Social Security home page.
Exit
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Paperwork Reduction Act Statement
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Paperwork Reduction Act
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
45 minutes to read the instructions, gather the facts, and answer the questions.
You may send comments on our time estimate above to: Social Security Administration, 1338
Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate
to this address, not the completed form.
The OMB control number for this application is 0960-0696; expiration date 5/31/2008.
Close this window to return to the application.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg015.html [9/10/2007 7:30:32 AM]
Check The Social Security Number You Entered
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Check The Social Security Numbers You Entered
Our system cannot accept an application on at least one of the Social Security numbers you
entered: 743997047; 743991047.
Please check these numbers.
●
If you typed the wrong number(s), you will need to correct it before continuing.
●
If these are the correct Social Security numbers, contact Social Security to make other
arrangements to complete an application.
Be sure to tell the representative that you tried the online application and received this message.
To contact Social Security, call our toll-free number, 1-800-772-1213. If you are deaf or hard of
hearing, call our toll-free TTY number, 1-800-325-0778. Representatives are available Monday
through Friday from 7 a.m. to 7 p.m.
Previous
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg016_MARRIED.html [9/10/2007 7:30:32 AM]
Check The Social Security Number You Entered
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Check The Social Security Number You Entered
Our system cannot accept an application on the Social Security number you entered: 743991047.
Please check this number.
●
If you typed the wrong number, you will need to correct it before continuing.
●
If this is your correct Social Security number, contact Social Security to make other
arrangements to complete an application.
Be sure to tell the representative that you tried the online application and received this message.
To contact Social Security, call our toll-free number, 1-800-772-1213. If you are deaf or hard of
hearing, call our toll-free TTY number, 1-800-325-0778. Representatives are available Monday
through Friday from 7 a.m. to 7 p.m.
Previous
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg016_SINGLE.html [9/10/2007 7:30:33 AM]
Sign-In Problem
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign-In Problem
We could not find a match for the Social Security number and Reentry Number you entered.
Please check the numbers and sign in again. You can retry no more than three times.
If you can not sign in after three tries, your application will be locked. You can start a new
application or call us to apply. To ensure your privacy, we cannot access your Reentry Number.
To contact Social Security, call our toll-free number, 1-800-772-1213. If you are deaf or hard of
hearing, call our toll-free TTY number, 1-800-325-0778. Representatives are available Monday
through Friday from 7 a.m. to 7 p.m.
Reentry Sign In
Start A New Application
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There Is A Pending Application For This Social Security Number
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
There Is A Pending Application For This Social Security Number
Based on the Social Security number you entered, it appears that you have already started to
complete this application. To continue with the application you already started, select Reentry Sign
In. If you have not already started an application, check the Social Security number you entered and
reenter it by selecting Previous.
If you have lost your Reentry Number, you can start over, but you will lose all of the information you
already entered. To ensure your privacy, we cannot access your Reentry Number.
If you decide to start over, select Start a New Application. Starting a new application does NOT
extend the time you have to complete this application. You may lose benefits if we do not receive
your application within 60 days from when you first started completing an online application.
To contact Social Security, call our toll-free number, 1-800-772-1213. If you are deaf or hard of
hearing, call our toll-free TTY number, 1-800-325-0778. Representatives are available Monday
through Friday from 7 a.m. to 7 p.m.
Reentry Sign In
Start A New Application
Previous
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You Have Already Sent Us An Application
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
You Have Already Sent Us An Application
An Application for Help With Medicare Prescription Drug Plan Costs has already been electronically
submitted to Social Security for this applicant. If you have new information, you must contact us. We
cannot accept additional information over the Internet. Please contact Social Security if the
information you submitted is wrong or you want to report a change in:
●
Address or phone number
●
Marital status
●
Income
●
Money, investments, or real estate
To contact Social Security, call our toll-free number, 1-800-772-1213. If you are deaf or hard of
hearing, call our toll-free TTY number, 1-800-325-0778. Representatives are available Monday
through Friday from 7 a.m. to 7 p.m.
Exit
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg019.html [9/10/2007 7:30:34 AM]
How The Online Application Works
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
How The Online Application Works
This application does not have to be completed all at once. After you fill in your name and address,
you will get a Reentry Number. You will be able to stop working on the application whenever you
want, and then use this Reentry Number to come back. Each application has its own Reentry
Number that can only be used for that application on the web site.
When you have completed the application, you will get a full summary of the information you
entered. You can make any necessary changes prior to submission. After you send the application
to us electronically, you will be able to print or save a receipt, and your submitted application.
Please read the following information about using this online application:
●
Select Continue to move forward, or Previous to move backward. Both options are located at
the bottom of the page. Do NOT use the Back button on your browser to move backward.
●
IMPORTANT: Do not use the Enter key to move around in the application or to select from
the drop-down lists.
●
Additional buttons, other than Continue and Previous, may appear at the bottom of a page.
These buttons allow you to take an action such as returning to the Review page.
●
You must complete all required information before you can send us the application. After the
data entry pages, you will see a list of the pages with missing information. You will not be
able to sign and submit the application to us until you fix all the errors and provide the
missing information.
●
If you Sign Out of the application before completing this basic information, when you return
to the application we will return you to the page where you left off.
●
Additional information may appear in a pop-up window. Close this window to return to the
application.
●
Keyboard commands, hotkeys or access keys will vary based upon browser and the version
of that browser that you are using. A list of these commands can be found in the Help section
of your browser. The Help feature can be located on the Menu bar of your browser or by
using the F1 function key on the keyboard. Any assistive devices that you may be using will
also have a list of these shortcut keys in the Help section. Also see our Keyboard
Commands web page.
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How The Online Application Works
●
Special Instructions for Blind Users.
Time Limits
There are time limits for your work on each page. You will receive a warning after 25 minutes and
you can extend your time on that page. After the third warning on a page, you must move to another
page or your time will run out and all your work on that page will be lost. If you have turned
JavaScript off in your browser, you will not receive these warnings and, after 30 minutes on a page,
you must go to another page or your application session will end, and your work on that page will be
lost.
Close this window to return to the application.
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Special Instructions For Blind Users
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Special Instructions For Users Who Are Blind
The following instructions are for users of screen readers such as JAWS and Window-Eyes and
browser-based readers such as Home Page Reader. Filling out this application is best
accomplished in a Forms or MSAA mode that allows you to tab to controls and fill in input boxes,
radio buttons, check boxes and list boxes. Instructional text usually occurs at the beginning of these
screens and can be accessed in non-MSAA or virtual-cursor mode. Tab indices have also been
added to allow for tabbing through text. Additionally, consistent headers have been set up to access
questions and examples/instructions more easily. The screen reader will indicate which questions
have additional help or instructional text. You can then tab to the additional help or continue tabbing
to the next question to bypass this help.
Unless you have turned JavaScript off in your browser, you will receive a warning after 25 minutes
and you can extend your time on the page. After the third warning, you must move to another page,
or your time will run out and your work on that page will be lost.
This application contains hotkeys to improve navigation and provide information. On many screens
there is a continue button at the end of the screen to allow you to go to the next page or a previous
button to return to the prior page. The hotkey ALT + C is associated with the Continue button and
ALT + P for the Previous button. Press ALT + C or ALT + P to move forward or back in Internet
Explorer. There is also a non-interactive progress indicator (ALT + G) which lets you know the step
of the application in which you are currently working. However, the use of this hotkey forces you to
leave your current position on the page as it moves focus to the top, where the progress indicator is
located.
Other keyboard commands, hotkeys or access keys will vary based upon browser and the version of
that browser that you are using. A list of these commands can be found in the Help section of your
browser. The Help feature can be located on the Menu bar of your browser or by using the F1
function key on the keyboard. Any assistive devices that you may be using will also have a list of
these shortcut keys in the Help section. Also see our Keyboard Commands web page.
When you attempt to advance through the application with erroneous data or missing information,
the page will redisplay with a list of links at the top for each error. Selecting these error links will take
you directly to the field in question, placing focus at the specific error control. The fixed error will not
be deleted from the list of links or error messages at the field until the page is re-submitted. To
navigate to the next error, invoke the screen reader or screen magnifier's links list or simply tab
through the fields and listen to the screen reader to hear when there is an error message.
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Special Instructions For Blind Users
There are instances where link and button names are repeated in an application like the following:
●
More Info
●
Edit
●
Details
These links usually have a title attribute that describes the link in more detail. In order for screen
readers to speak this additional information, the screen reader must be set up to speak the title
attribute instead of the screen text. Depending on the screen reader used, this can be a verbosity
setting, configuration setting, set file, etc. Please refer to the documentation for specific screen
readers or browser readers if this procedure is unknown.
Close this window to return to the application.
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Your Session Has Expired
Skip Navigation Bar
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Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Your Session Has Expired
If you would like to continue completing the application, you may try again by selecting Return To
Application below.
Select Exit to leave this application. You will be taken to the Social Security home page.
Exit
Return To Application
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg025.html [9/10/2007 7:30:36 AM]
We Cannot Process Your Request
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
We Cannot Process Your Request
We have not been able to match the information you entered with our records. If the information you
provided is correct, then it may be necessary to correct your information with Social Security.
To resolve this problem, call our toll-free number, 1-800-772-1213. If you are deaf or hard of
hearing, call our toll-free TTY number, 1-800-325-0778. Representatives are available Monday
through Friday from 7 a.m. to 7 p.m.
Select Exit to leave this application. You will be taken to the Social Security home page.
Exit
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg026.html [9/10/2007 7:30:37 AM]
System Failure
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
We Cannot Process Your Request At This Time
If you still wish to complete the application, you may:
●
Try again later,
●
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free
TTY number, 1-800-325-0778. Representatives are available Monday through Friday from 7
a.m. to 7 p.m.
Select Exit to leave this application. You will be taken to the Social Security home page.
Exit
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg027.html [9/10/2007 7:30:37 AM]
Off Hours Message
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
We Cannot Process Your Request
Please try again during business hours.
This service is available during the following hours (Eastern Time):
Monday through Friday: 5:00 AM - 1:00 AM
Saturday: 5:00 AM - 11:00 PM
Sunday: 8:00 AM - 10:00 PM
Holidays: 5:00 AM - 11:00 PM
Select Exit to leave this application. You will be taken to the Social Security home page.
Exit
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg028.html [9/10/2007 7:30:38 AM]
Limit Number Of Starts For A New Application
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
You Have Reached The Limit On The Number Of Requests To Reenter
The Application Already Started
You have reached the limit on the number of tries to reenter the Internet Application For Help With
Medicare Prescription Drug Plan Costs already started. You can start a new application or call us to
help you complete this application.
To ensure privacy, the prior application is now locked. If you start a new application, you will have to
reenter any information that was already entered.
To contact Social Security, call our toll-free number, 1-800-772-1213. If you are deaf or hard of
hearing, call our toll-free TTY number, 1-800-325-0778. Representatives are available Monday
through Friday from 7 a.m. to 7 p.m.
Start A New Application
Exit
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg029.html [9/10/2007 7:30:38 AM]
Processing Alert
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
We Are Processing This Request
Please wait a moment before selecting Continue.
Continue
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg030.html [9/10/2007 7:30:39 AM]
Limit Number Of Restarts
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Limit On The Number Of New Applications Started
You have reached the limit on the number of requests you can make to start a new application.
Please contact Social Security to make other arrangements to complete an application. Be sure to
tell the representative that you tried the online application and received this message.
To contact Social Security, call our toll-free number, 1-800-772-1213 . If you are deaf or hard of
hearing, call our toll-free TTY number, 1-800-325-0778 . Representatives are available Monday
through Friday from 7 a.m. to 7 p.m.
Select Exit to leave this application. You will be taken to the Social Security home page.
Exit
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg031.html [9/10/2007 7:30:39 AM]
Limit On The Number Of Tries To Start An Application
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Limit On The Number Of Tries To Start The Application
You have reached the limit on the number of tries to start this application.
Please contact Social Security to make other arrangements to complete this application. To contact
Social Security, call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our
toll-free TTY number, 1-800-325-0778. Representatives are available Monday through Friday from 7
a.m. to 7 p.m.
Select Exit to leave this application. You will be taken to the Social Security home page.
Exit
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg034.html [9/10/2007 7:30:40 AM]
Warning System Shutdown
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Warning: System Will Shut Down
This application for Help With Medicare Prescription Drug Plan Costs is scheduled to shut down for
the day within two hours.
This application is available during the following hours (Eastern Time):
Monday through Friday: 5:00 AM - 1:00 AM
Saturday: 5:00 AM - 11:00 PM
Sunday: 8:00 AM - 10:00 PM
Holidays: 5:00 AM - 11:00 PM
If you choose to start the application now and the system shuts down before you finish it, you will
only lose the information on the page you are working on at the time of the shutdown.
You may want to consider starting the application at another time to avoid losing any information. If
you decide to start this application later, you should write down this web site so that you can return
to it: http:www.socialsecurity.gov/prescriptionhelp
If you decide to leave this application, select Exit. You will be taken to the Social Security home
page.
Apply Now
Exit
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg045.html [9/10/2007 7:30:40 AM]
Please Confirm
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Please Confirm
You said earlier you are not under 65 years old, and now you would like to change your answer.
To confirm, please answer the question below.
Note: Changing your answer may delete information you have provided about this question or
require you to provide additional information.
Are you UNDER 65 years old? More
Info
No
Yes
Continue
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg047_65_SELF.html [9/10/2007 7:30:41 AM]
Please Confirm
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Please Confirm
You said earlier your spouse is not under 65 years old, and now you would like to change your
answer.
To confirm, please answer the question below.
Note: Changing your answer may delete information you have provided about this question or
require you to provide additional information.
Is your spouse UNDER 65 years old? More
Info
No
Yes
Continue
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg047_65_SPOUSE.html [9/10/2007 7:30:41 AM]
Please Confirm
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Please Confirm
You said earlier you have worked in this calendar year, and now you would like to change your
answer.
To confirm, please answer the question below.
Note: Changing your answer may delete information you have provided about this question or
require you to provide additional information.
Have you worked in this calendar year? More
Info
No
Yes
Continue
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg047_WORKED_1Y.html [9/10/2007 7:30:42 AM]
Please Confirm
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Please Confirm
You said earlier your spouse has not worked in this calendar year, and now you would like to
change your answer.
To confirm, please answer the question below.
Note: Changing your answer may delete information you have provided about this question or
require you to provide additional information.
Has your spouse worked in this calendar year? More
Info
No
Yes
Continue
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg047_WORKED_1Y_SPOUSE.html [9/10/2007 7:30:42 AM]
Please Confirm
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Please Confirm
You said earlier you have worked in 2006 or 2007, and now you would like to change your answer.
To confirm, please answer the question below.
Note: Changing your answer may delete information you have provided about this question or
require you to provide additional information.
Have you worked in 2006 or 2007? More
Info
No
Yes
Continue
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg047_WORKED_2Y.html [9/10/2007 7:30:43 AM]
Please Confirm
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Please Confirm
You said earlier your spouse has worked in 2006 or 2007, and now you would like to change your
answer.
To confirm, please answer the question below.
Note: Changing your answer may delete information you have provided about this question or
require you to provide additional information.
Has your spouse worked in 2006 or 2007? More
Info
No
Yes
Continue
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg047_WORKED_2Y_SPOUSE.html [9/10/2007 7:30:43 AM]
Other Ways To Apply
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Other Ways To Apply
If you prefer not to fill out this application on the Internet, you can call our toll-free
number, 1-800-772-1213 for a paper application or to make an appointment. If you are deaf or hard
of hearing, call our toll-free TTY number, 1-800-325-0778. Representatives are available Monday
through Friday from 7 a.m. to 7 p.m. Tell the representative that you want to apply for the Help with
Medicare Prescription Drug Costs.
Close this window to return to the application.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg061.html [9/10/2007 7:30:44 AM]
Print/Save/View Guide
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
How To Print/Save/View This Application
To print this application:
Choose the Print button on your browser button bar or choose Print from the File menu. Make sure
the correct printer is selected and choose OK.
To save this application:
Choose Save As from the File menu. We recommend that you save as an HTML file. Provide a file
name and location, if needed, and choose OK.
To view the saved page:
Open your browser. Choose Open from the File menu. Click Browse and locate the file name and
location you used. (When you reopen this HTML file, none of the buttons or links on the page will
work.)
Close this window to return to the application.
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Not Eligible For The Prescription Drug Plan
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
If You Are Not Eligible For Medicare
You must have Medicare or be eligible for Medicare in order to participate in the prescription drug
plan. If you have a state-issued medical assistance card (Medicaid), you should contact your state
agency.
Select Exit to leave this application. You will be taken to the Social Security home page.
Previous
Exit
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Name Check Mismatch
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Check The Information You Entered
The information you entered does not match our records.
●
If you typed the wrong information, you will need to correct it before continuing.
●
If the information is correct, please confirm it by reentering the same information.
●
To do either of the above, select Previous.
If you prefer, you can contact Social Security to make other arrangements to complete an
application. Be sure to tell the representative that you tried completing the online application and
received this message.
To contact Social Security, call our toll-free number, 1-800-772-1213. If you are deaf or hard of
hearing, call our toll-free TTY number, 1-800-325-0778. Representatives are available Monday
through Friday from 7 a.m. to 7 p.m.
Previous
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Authentication - Medicare Part D Database Not Eligible Or SSI Recipient
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
We Cannot Process Your Request
We have not been able to match the information you entered with our records. If the information you
provided is correct, then it may be necessary to correct your information with Social Security.
To resolve this problem, call our toll-free number, 1-800-772-1213. If you are deaf or hard of
hearing, call our toll-free TTY number, 1-800-325-0778. Representatives are available Monday
through Friday from 7 a.m. to 7 p.m.
Select Exit to leave this application. You will be taken to the Social Security home page.
Exit
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/msg105.html [9/10/2007 7:30:46 AM]
What You Will Need
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
What You Will Need
To determine if you could be eligible for help with prescription drug plan costs, Social Security needs
information about your (and your spouse's, if married and living together) income and resources.
Documents that may help you prepare include:
●
Social Security card;
●
bank account statements, including checking, savings, and certificates of deposit;
●
Individual Retirement Accounts (IRA), stocks, bonds, savings bonds (including book entry
securities*), mutual funds, other investment statements;
●
tax returns;
●
payroll slips;
●
your most recent Social Security benefits award letters or statements for Railroad Retirement
income, Veterans benefits, pensions and annuities; and
●
the cash value and face value of any life insurance policies you have. Check with your
insurance agent for the exact amount you would get if you cashed in your life insurance
policies today.
* Book Entry Securities In addition to traditional U.S. Savings Bonds, individuals now may go to the Treasury
Department's Internet site and make online purchases of electronic savings bonds. Electronic savings bonds
are also called "book entry securities." With book entry securities, the individual's investment is recorded
electronically by the Treasury Department and a paper savings bond is not issued. If you have book entry
securities, they are counted as resources and should be reported on this application.
If you do not have these documents, provide us with your best estimate so that we can tell you
whether you are likely to qualify for extra help with your prescription drug costs. This information is
to help you complete the application. You will not have to submit the documents unless contacted by
a Social Security representative.
Close this window to return to the application.
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Find Out If You And Your Spouse Qualify: Part 1 - Married
Skip Navigation Bar
Help With Medicare Prescription Drug Plan
Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Find Out If You
Qualify
Complete
Application
Review
Submit
Print
Receipt
Find Out If You And Your Spouse Qualify: Part 1
The next few pages provide a tool that can tell you if you are likely to qualify for extra help to pay for your prescription
drug costs so that you do not have to go through the entire application process unnecessarily. If this tool suggests that
it is unlikely you will qualify, you may still apply. We will save your answers only if you decide to apply now. You may
change your answers at any time until you submit your application.
Have you or your spouse worked in this calendar year? More Info
You
Change This Answer
No
Spouse
Yes
Change This Answer
No
Yes
Are you or your spouse UNDER age 65? More Info
You
Change This Answer
No
Spouse
Yes
Change This Answer
No
Yes
Not counting your spouse, how many other relatives live in your household and receive at least one-half of
their financial support from you or your spouse? Do NOT include yourself or your spouse in the number you
enter. If your household consists only of you and your spouse, enter "0." More Info
We ask this because your household size may affect the amount of help you can get. We count relatives related to
you by blood, marriage or adoption.
0
Do you count on anyone to help pay for any of the following household expenses? More Info
●
Food
●
Heating Fuel or Gas
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Find Out If You And Your Spouse Qualify: Part 1 - Married
●
Mortgage
●
Electricity and Water
●
Rent
●
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.
No
Yes, they provide: $ 250.00
per month
(If the amount changes from month to month or you do not receive it every month, enter the average monthly amount
for the past year.)
Previous
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Continue
Find Out If You And Your Spouse Qualify: Part 1 - Married
Skip Navigation Bar
Help With Medicare Prescription Drug Plan
Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Find Out If You
Qualify
Complete
Application
Review
Submit
Print
Receipt
Find Out If You And Your Spouse Qualify: Part 1
The next few pages provide a tool that can tell you if you are likely to qualify for extra help to pay for your prescription
drug costs so that you do not have to go through the entire application process unnecessarily. If this tool suggests that
it is unlikely you will qualify, you may still apply. We will save your answers only if you decide to apply now. You may
change your answers at any time until you submit your application.
Have you or your spouse worked in this calendar year? More Info
You
No
Yes
Spouse
No
Yes
Are you or your spouse UNDER age 65? More Info
You
No
Yes
Spouse
No
Yes
Not counting your spouse, how many other relatives live in your household and receive at least one-half of
their financial support from you or your spouse? Do NOT include yourself or your spouse in the number you
enter. If your household consists only of you and your spouse, enter "0." More Info
We ask this because your household size may affect the amount of help you can get. We count relatives related to
you by blood, marriage or adoption.
Do you count on anyone to help pay for any of the following household expenses? More Info
●
Food
●
Heating Fuel or Gas
●
Mortgage
●
Electricity and Water
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Find Out If You And Your Spouse Qualify: Part 1 - Married
●
Rent
●
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.
No
Yes, they provide: $
per month
(If the amount changes from month to month or you do not receive it every month, enter the average monthly amount
for the past year.)
Previous
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Continue
Find Out If You Qualify: Part 1 - Single
Skip Navigation Bar
Help With Medicare Prescription Drug Plan
Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Find Out If You
Qualify
Complete
Application
Review
Submit
Print
Receipt
Find Out If You Qualify: Part 1
The next few pages provide a tool that can tell you if you are likely to qualify for extra help to pay for your prescription
drug costs so that you do not have to go through the entire application process unnecessarily. If this tool suggests that
it is unlikely you will qualify, you may still apply. We will save your answers only if you decide to apply now. You may
change your answers at any time until you submit your application.
Have you worked in this calendar year? More Info
No
Yes
Are you UNDER age 65? More Info
No
Yes
How many relatives live in your household and receive at least one-half of their financial support from you? Do
NOT include yourself in the number you enter. If your household consists only of you, enter "0." More Info
We ask this because your household size may affect the amount of help you can get. We count relatives related to
you by blood, marriage or adoption.
Do you count on anyone to help pay for any of the following household expenses? More Info
●
Food
●
Heating Fuel or Gas
●
Mortgage
●
Electricity and Water
●
Rent
●
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.
No
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Find Out If You Qualify: Part 1 - Single
Yes, they provide: $
per month
(If the amount changes from month to month or you do not receive it every month, enter the average monthly amount
for the past year.)
Previous
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Continue
Find Out If You And Your Spouse Qualify: Part 3 - Married
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Find Out If You
Qualify
Complete
Application
Review
Submit
Print
Receipt
Find Out If You And Your Spouse Qualify: Part 3 Of 3
Please continue to enter the information below so that we can tell you if you are likely to qualify for
extra help.
You told us that you worked this calendar year. If this is not correct, please
Change This Answer
You told us that your spouse worked this calendar year. If this is not correct, please
Change This Answer
Do you or your spouse have to pay for things related to a disability or blindness that enable
you to work? More Info
We will only count part of your earnings towards 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
modification, driver assistance, or other special work-related transportation needs; work-related
assistive technology; guide dog expenses; sensory and visual aids; and Braille translations.
You
No
Yes, for blindness
Yes, for a
disability
Spouse
No
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Find Out If You And Your Spouse Qualify: Part 3 - Married
Yes, for blindness
Yes, for a
disability
What do you or your spouse expect to earn in wages before taxes and deductions this
calendar year? More Info
You
None
year
Spouse
Wages of: $
None
year
this
Wages of: $
this
What do your or your spouse expect your net earnings from self-employment to be this
calendar year? More Info
You
None
Net EARNINGS of: $
year
this
Net LOSS
Spouse
None
Net EARNINGS of: $
year
this
Net LOSS
Have you or your spouse stopped working in 2006 or 2007, or plan to stop working in 2007 or
2008? More Info
You
No
Yes, stopped/plan to stop: Month
Year
Spouse
No
Yes, stopped/plan to stop: Month
Year
Previous
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Continue
Find Out If You Qualify: Part 3 - Single
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Find Out If You
Qualify
Complete
Application
Review
Submit
Print
Receipt
Find Out If You Qualify: Part 3 Of 3
Please continue to enter the information below so that we can tell you if you are likely to qualify for
extra help.
You told us that you worked this calendar year. If this is not correct, please
Change This Answer
Do you have to pay for things related to a disability or blindness that enable you to work?
More Info
We will count only a part of your earnings towards 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
modification, driver assistance, or other special work-related transportation needs; work-related
assistive technology; guide dog expenses; sensory and visual aids; and Braille translations.
No
Yes, for blindness
Yes, for a
disability
What do you expect to earn in wages before taxes and deductions this calendar year? More
Info
None
Wages of: $
this
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Find Out If You Qualify: Part 3 - Single
year
What do you expect your net earnings from self-employment to be this calendar year? More
Info
None
Net EARNINGS of: $
year
this
Net LOSS
Have you stopped working in 2006 or 2007, or plan to stop working in 2007 or 2008? More
Info
No
Yes, stopped/plan to stop: Month
Year
Previous
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Find Out If You Qualify: Part 3 - Single
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Find Out If You
Qualify
Complete
Application
Review
Submit
Print
Receipt
Find Out If You Qualify: Part 3 Of 3
Please continue to enter the information below so that we can tell you if you are likely to qualify for
extra help.
You told us that you worked this calendar year. If this is not correct, please
Change This Answer
What do you expect to earn in wages before taxes and deductions this calendar year? More
Info
None
year
Wages of: $
this
What do you expect your net earnings from self-employment to be this calendar year? More
Info
None
Net EARNINGS of: $
year
this
Net LOSS
Have you stopped working in 2006 or 2007, or plan to stop working in 2007 or 2008? More
Info
No
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Find Out If You Qualify: Part 3 - Single
Yes, stopped/plan to stop: Month
Year
Previous
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Find Out If You Qualify: Part 2 Of 2
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Find Out If You
Qualify
Complete
Application
Review
Submit
Print
Receipt
Find Out If You Qualify: Part 2 Of 2
Please continue to enter the information below so that we can tell you if you are likely to qualify for extra help.
If you or your spouse 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 fields.
Do NOT list wages and self-employment, interest income, public assistance, medical reimbursements or foster care
payments here. If you do not receive income from a source listed below, select No for that source.
If you need help adding your pensions or annuities, select Add Pensions Or Annuities. If you need help adding your
other income, select Add Other Income. The total dollar amount calculated will appear in the dollar amount field on
this page when Add And Use Total is selected on the page calculating the totals.
Do you or your spouse receive Social Security benefits? More Info
You
Yes, $ 250.00
No
per month (before
deductions)
Spouse
Yes, $ 250.00
No
per month (before
deductions)
Do you or your spouse receive Railroad Retirement income? More Info
You
Yes, $ 250.00
No
per month (before
deductions)
Spouse
No
Yes, $
per month (before
deductions)
Do you or your spouse receive Veterans benefits? More Info
You
No
Yes, $ 250.00
per month (before
deductions)
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Find Out If You Qualify: Part 2 Of 2
Spouse
No
per month (before
Yes, $
deductions)
Do you or your spouse receive income from other pensions or annuities? More Info
You
Yes, $ 250.00
No
per month (before deductions)
Add Pensions Or Annuities
(Do NOT include annuities from certificates of deposit, stocks, bonds, mutual funds, IRAs or any other
investments.)
Spouse
No
per month (before deductions)
Yes, $
Add Pensions Or Annuities
Do you or your spouse receive other income not listed above, including alimony, net rental income,
workers' compensation, etc.?
More Info
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings bonds, mutual
funds, IRAs or any similar investments, or any other cash at home or anywhere else.)
You
No
Yes
If Yes, specify monthly amount and type(s):
Amount: $
per month
Add Other Income
Type:
Spouse
No
Yes
If Yes, specify monthly amount and type(s):
Amount: $
per month
Add Other Income
Type:
Previous
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Find Out If You Qualify: Part 2 Of 3
Skip Navigation Bar
Help With Medicare Prescription Drug
Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Find Out If You
Qualify
Complete
Application
Review
Submit
Print
Receipt
Find Out If You Qualify: Part 2 Of 3
Please continue to enter the information below so that we can tell you if you are likely to qualify for extra help.
If you 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 fields.
Do NOT list wages and self-employment, interest income, public assistance, medical reimbursements or foster care
payments here. If you do not receive income from a source listed below, select No for that source.
If you need help adding your pensions or annuities, select Add Pensions Or Annuities. If you need help adding your
other income, select Add Other Income. The total dollar amount calculated will appear in the dollar amount field on
this page when Add And Use Total is selected on the page calculating the totals.
Do you receive Social Security benefits? More Info
No
Yes, $
per month (before
deductions)
Do you receive Railroad Retirement income? More Info
No
Yes, $
per month (before
deductions)
Do you receive Veterans benefits? More Info
No
Yes, $
per month (before
deductions)
Do you receive income from other pensions or annuities? More Info
(Do NOT include annuities from certificates of deposit, stocks, bonds, mutual funds, IRAs or any other
investments.)
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Find Out If You Qualify: Part 2 Of 3
No
per month (before deductions)
Yes, $
Add Pensions Or Annuities
Do you receive other income not listed above, including alimony, net rental income, workers'
compensation, etc.? More Info
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings bonds, mutual
funds, IRAs or any similar investments, or any other cash at home or anywhere else.)
No
Yes
If Yes, specify monthly amount and type(s):
Amount: $
per month
Add Other Income
Type:
Previous
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Find Out If You Qualify: Results - You Should Apply
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Find Out If You
Qualify
Complete
Application
Review
Submit
Print
Receipt
Find Out If You Qualify: Results - You Should Apply
Based on the answers you provided, you probably qualify for the extra help with
prescription drug costs.
What You Can Do Next
1. You may begin the application process by selecting Apply Now,
2. You may go back to make changes by selecting Previous, or
3. You may select Start Over to reenter your information.
If you select Apply Now, you will get a Reentry Number after you fill in your name and address. If
you choose to Sign Out of this application before it is complete, you may use your Reentry Number
at any time to come back. You will also be able to change your answers later.
What You Will Need To Apply
If you decide to complete this application, we will ask about your income (and your spouse's income,
if married and living together) and the things that you and your spouse own. Documents that may
help you prepare include:
●
Social Security card;
●
bank account statements, including checking, savings, and certificates of deposit;
●
Individual Retirement Accounts (IRAs), stocks, bonds, savings bonds, mutual funds, other
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Find Out If You Qualify: Results - You Should Apply
investment statements;
●
tax returns;
●
payroll slips;
●
your most recent award letters or statements for Railroad Retirement income, Veterans
benefits, pensions and annuities; and
●
the cash and face values of any life insurance policies you have. Check with your insurance
agent for the exact amount you would get if you cashed in your life insurance policies today.
If you do not have these documents, provide us with your best estimate so that we can tell you
whether you are likely to qualify for extra help with your prescription drug costs. This information is
to help you complete the application. You will not have to submit the documents unless contacted by
a Social Security representative.
Start Over
Previous
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Apply Now
Find Out If You Qualify: Results - You Probably Do Not Qualify
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Need Help?
Step:
Find Out If You
Qualify
Complete
Application
Review
Submit
Print
Receipt
Find Out If You Qualify: Results - You Probably Do Not Qualify
Based on the answers you provided, you probably do not qualify for extra help.
You do not need to complete this application. However, if there is any doubt about
your entries or you need a letter stating you are not eligible, complete the
application. Whether or not you qualify for the extra help, you may still enroll in an
approved Medicare prescription drug plan for coverage. For information about
enrolling in a prescription drug plan, call 1-800-MEDICARE (TTY 1-877-486-2048)
or visit www.medicare.gov.
What You Can Do Next
1. You may begin the application process by selecting Apply Now,
2. You may go back to make changes by selecting Previous,
3. You may select Start Over to reenter your information, or
4. You may Exit the application.
If you select Apply Now, you will get a Reentry Number after you fill in your name and address. If
you choose to Sign Out of this application before it is complete, you may use your Reentry Number
at any time to come back. You will also be able to change your answers later.
What You Will Need To Apply
If you decide to complete this application, we will ask about your income (and your spouse's income,
if married and living together) and the things that you and your spouse own. Documents that may
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Find Out If You Qualify: Results - You Probably Do Not Qualify
help you prepare include:
●
Social Security card;
●
bank account statements, including checking, savings, and certificates of deposit;
●
Individual Retirement Accounts (IRAs), stocks, bonds, savings bonds, mutual funds, other
investment statements;
●
tax returns;
●
payroll slips;
●
your most recent award letters or statements for Railroad Retirement income, Veterans
benefits, pensions and annuities; and
●
the cash and face values of any life insurance policies you have. Check with your insurance
agent for the exact amount you would get if you cashed in your life insurance policies today.
If you do not have these documents, provide us with your best estimate so that we can tell you
whether you are likely to qualify for extra help with your prescription drug costs. This information is
to help you complete the application. You will not have to submit the documents unless contacted by
a Social Security representative.
Start Over
Previous
Apply Now
Exit
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Review Your Information
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
Complete
Application
Need Help?
Review
Submit
Print
Receipt
Review Your Information
Review the items you completed below before you submit this application. If you need to make
changes, select the Edit button in the margin just left of the section where the changes are
necessary. Changes on one page may require additional information to be entered or changed on
subsequent pages. You can print this summary before you submit it. Once you submit it, you will be
able to print a receipt that shows exactly what is on your application.
About the Form Completer
Name:
Relationship:
Form
Family
Completer Member
Phone: Address:
(111)
123 Main
111Street
1111
Anywhere,
SC 34567
Edit
About You and Your Spouse
Edit
Applicants:
Both my
spouse and
I are
applying.
Work
Status:
I did not
work in
2006 or
2007.
My spouse
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Review Your Information
Edit
Edit
Edit
did not
work in
2006 or
2007.
We do not
have
combined
savings,
investments,
and real
estate
worth more
than
$23,410.
My
Information:
John Doe
743-996047
Date of
birth:
January 1,
1900
My
Spouse:
Jane
Doe
743-991047
Date of
birth:
February
2, 1901
Mailing
Address/
Phone:
123 Main
Street
Anywhere,
SC
34567
(540) 5559876
We have
not
changed
our
address
within the
last three
months.
Contact
Person:
None
given
About You And Your Spouse's Living Situation
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Review Your Information
Edit
Edit
Number of
dependents:
0
Support:
No one
helps us
pay for
household
expenses.
Resources
Edit
Edit
Bank
accounts,
investments,
cash:
We have no
bank
accounts.
We have no
stocks,
bonds,
savings
bonds,
mutual
funds,
Individual
Retirement
Accounts, or
similar
investments.
We have no
cash at
home or
anywhere
else.
Life
insurance
policies:
I do not
have life
insurance
policies
with a
total face
value of
more
than
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Review Your Information
Edit
Edit
$1,500.
My
spouse
does not
have life
insurance
policies
with a
total face
value of
more
than
$1,500.
Burial
expenses:
Some
money
from the
sources
above will
be used
to pay for
my
funeral or
burial
expenses.
Some
money
from the
sources
above will
be used
to pay for
my
spouse's
funeral or
burial
expenses.
Real
estate:
We do
not
own
any
real
estate
other
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Review Your Information
than
our
home
and the
property
on
which it
is
located.
Income Other Than Wages and Earnings
Edit
Income
from
pensions,
annuities
and other
sources:
I did not
answer
the
question
about
receiving
Social
Security
benefits.
I did not
answer
the
question
about my
spouse
receiving
Social
Security
benefits.
I do not
receive
Railroad
Retirement
income.
My
spouse
does not
receive
Railroad
Retirement
income.
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Edit
I do not
receive
Veterans
benefits.
My
spouse
does not
receive
Veterans
benefits.
I receive
$500.00
per month
from other
pensions
or
annuities.
My
spouse
does not
receive
other
pensions
or
annuities.
I receive
$500.00
per month
from other
income.
Type:
Other
Income
My
spouse
does not
receive
other
income.
Decrease
in
income
other
than
wages
and
earnings:
Our
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Review Your Information
income
from
these
sources
has not
decreased
in the last
two years.
Continue
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Review Your Information
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
Complete
Application
Need Help?
Review
Submit
Print
Receipt
Review Your Information
Review the items you completed below before you submit this application. If you need to make
changes, select the Edit button in the margin just left of the section where the changes are
necessary. Changes on one page may require additional information to be entered or changed on
subsequent pages. You can print this summary before you submit it. Once you submit it, you will be
able to print a receipt that shows exactly what is on your application.
About You and Your Spouse
Edit
Applicants:
I am
applying.
My spouse
is not
applying.
Work
Status:
I worked in
2006 or
2007.
My spouse
worked in
2006 or
2007.
We do not
have
combined
savings,
investments,
and real
estate
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Review Your Information
Edit
Edit
Edit
worth more
than
$23,410.
My
Information:
John Doe
743-993047
Date of
birth:
January 1,
1960
My
Spouse:
Jane
Doe
743-991047
Date of
birth:
February
2, 1901
Mailing
Address/
Phone:
123 Main
Street
Anywhere,
SC
34567
(540) 5559876
We have
not
changed
our
address
within the
last three
months.
Contact
Person:
None
given
About You And Your Spouse's Living Situation
Edit
Number of
dependents:
You did
not enter
the number
of
dependents.
Edit
Support:
You
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did not
answer
whether
anyone
helps you
or your
spouse
pay for
household
expenses.
Resources
Edit
Bank
accounts,
investments,
cash:
You did
not give us
information
about your
bank
accounts.
You did
not answer
whether you
have any
stocks,
bonds,
savings
bonds,
mutual
funds,
Individual
Retirement
Accounts, or
similar
investments.
You did
not answer
whether you
have any
other cash
at home or
anywhere
else.
Edit
Life
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Review Your Information
insurance
policies:
You
did not
answer
whether
you have
life
insurance
policies
with a
total face
value of
more
than
$1,500.
You
did not
answer
whether
your
spouse
has life
insurance
policies
with a
total face
value of
more
than
$1,500.
Edit
Burial
expenses:
Some
money
from the
sources
above will
be used
to pay for
my
funeral or
burial
expenses.
Some
money
from the
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Review Your Information
Edit
sources
above will
be used
to pay for
my
spouse's
funeral or
burial
expenses.
Real
estate:
You
did not
answer
whether
you
own
any
real
estate
other
than
your
home
and the
property
on
which it
is
located.
Income Other Than Wages and Earnings
Edit
Income
from
pensions,
annuities
and other
sources:
I did not
answer
the
question
about
receiving
Social
Security
benefits.
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I did not
answer
the
question
about my
spouse
receiving
Social
Security
benefits.
I do not
receive
Railroad
Retirement
income.
My
spouse
does not
receive
Railroad
Retirement
income.
I do not
receive
Veterans
benefits.
My
spouse
does not
receive
Veterans
benefits.
I do not
receive
other
pensions
or
annuities.
My
spouse
does not
receive
other
pensions
or
annuities.
I do not
receive
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Edit
other
income.
My
spouse
does not
receive
other
income.
Decrease
in
income
other
than
wages
and
earnings:
Our
income
from
these
sources
has not
decreased
in the last
two years.
Wages and Earnings
Edit
Pre-tax
wages
this
calendar
year:
I do not
expect
to earn
wages
this
calendar
year.
My
spouse
does
not
expect
to earn
wages
this
calendar
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Review Your Information
Edit
Edit
Edit
year.
Selfemployment
net
earnings
this
calendar
year:
I expect to
earn
$1,200.00.
My spouse
expects to
earn
$1,300.00.
Decrease
in wages
and/or net
selfemployment
earnings:
Our income
from wages
and/or net
selfemployment
earnings
has not
decreased
in the last
two years.
Work
plans:
I did
not
stop
working
in
2006
or
2007,
and do
not
plan to
stop in
2007
or
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Edit
2008.
My
spouse
did not
stop
working
in
2006
or
2007,
and
does
not
plan to
stop in
2007
or
2008.
Disabilityrelated
expenses:
I do not
pay for
things
related to
disability
or
blindness
that
enable
me to
work.
You must provide the missing information before you can continue to submit this application.
Previous
Continue
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Ready To Submit
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
Complete
Application
Need Help?
Review
Submit
Print
Receipt
Ready To Submit?
If you are ready to submit your Application for Help With Medicare Prescription Drug Plan Costs,
read the statements below. Checking the box next to your name means that you agree with the
statements and have signed your application.
I, John Doe, understand that the Social Security Administration (SSA) will check my 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 authorizing SSA to obtain and disclose information related to my
income, resources, and assets, foreign and domestic, consistent with applicable privacy laws. This
information may include, but is not limited to, information about my wages, account balances,
investments, insurance policies, benefits, and pensions.
I declare under penalty of perjury that I have examined all the information on this form, and it is true
and correct to the best of my knowledge.
I, Jane Doe, understand that the Social Security Administration (SSA) will check my 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 authorizing SSA to obtain and disclose information related to my
income, resources, and assets, foreign and domestic, consistent with applicable privacy laws. This
information may include, but is not limited to, information about my wages, account balances,
investments, insurance policies, benefits, and pensions.
I declare under penalty of perjury that I have examined all the information on this form, and it is true
and correct to the best of my knowledge.
Important: After you submit this application, you will not be able to come back
to it. Check the box next to your name to indicate that you have read and are
signing the statement below.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs003_NO_MARRIED_BOTH.html (1 of 2) [9/10/2007 7:30:59 AM]
Ready To Submit
I, John Doe, read and agree with the above.
I, Jane Doe, read and agree with the above.
Previous
Submit Now
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Help With Medicare Prescription
Drug Plan Costs
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Ready To Submit?
If you are ready to submit your Application for Help With Medicare Prescription Drug Plan Costs,
read the statements below. Checking the box next to your name means that you agree with the
statements and have signed your application.
I, John Doe, understand that the Social Security Administration (SSA) will check my 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 authorizing SSA to obtain and disclose information related to my
income, resources, and assets, foreign and domestic, consistent with applicable privacy laws. This
information may include, but is not limited to, information about my wages, account balances,
investments, insurance policies, benefits, and pensions.
I declare under penalty of perjury that I have examined all the information on this form, and it is true
and correct to the best of my knowledge.
I, Jane Doe, understand that by signing this application, I am authorizing Social Security to obtain
and disclose information related to my income, resources, and assets, foreign and domestic,
consistent with applicable privacy laws. This information may include, but is not limited to,
information about my wages, account balances, investments, insurance policies, benefits, and
pensions.
Important: After you submit this application, you will not be able to come back
to it. Check the box next to your name to indicate that you have read and are
signing the statement below.
I, John Doe, read and agree with the above.
I, Jane Doe, read and agree with the above.
Previous
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Drug Plan Costs
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Ready To Submit?
If you are ready to submit your Application for Help With Medicare Prescription Drug Plan Costs,
read the statement below. Checking the box next to your name means that you agree with the
statement and have signed your application.
I, John Doe, understand that the Social Security Administration (SSA) will check my 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 authorizing SSA to obtain and disclose information related to my
income, resources, and assets, foreign and domestic, consistent with applicable privacy laws. This
information may include, but is not limited to, information about my wages, account balances,
investments, insurance policies, benefits, and pensions.
I declare under penalty of perjury that I have examined all the information on this form, and it is true
and correct to the best of my knowledge.
Important: After you submit this application, you will not be able to come back
to it. Check the box next to your name to indicate that you have read and are
signing the statement below.
I, John Doe, read and agree with the above.
Previous
Submit Now
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs003_NO_SINGLE.html [9/10/2007 7:31:00 AM]
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Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
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Submit
Print
Receipt
Ready To Submit?
If you are ready to submit your Application for Help With Medicare Prescription Drug Plan Costs,
read the statement below. Checking the box next to your name means that you agree with the
statement and have signed your application.
I, Form Completer, am assisting John Doe and Jane Doe in submitting this application. I
understand that the Social Security Administration (SSA) will check my 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 authorizing SSA to obtain and disclose information related to the
applicant's income, resources, and assets, foreign and domestic, consistent with applicable privacy
laws. This information may include, but is not limited to, information about the applicant's wages,
account balances, investments, insurance policies, benefits, and pensions.
I declare under penalty of perjury that I have examined all the information on this form, and it is true
and correct to the best of my knowledge.
Important: After you submit this application, you will not be able to come back
to it. Check the box next to your name to indicate that you have read and are
signing the statement below.
I, Form Completer, read and agree with the above.
Previous
Submit Now
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs003_YES_MARRIED.html [9/10/2007 7:31:01 AM]
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Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Sign Out (Finish this Later)
Step:
Complete
Application
Need Help?
Review
Submit
Print
Receipt
Ready To Submit?
If you are ready to submit your Application for Help With Medicare Prescription Drug Plan Costs,
read the statement below. Checking the box next to your name means that you agree with the
statement and have signed your application.
I, Form Completer, am assisting John Doe in submitting this application. I understand that the
Social Security Administration (SSA) will check my 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 authorizing SSA to obtain and disclose information related to the
applicant's income, resources, and assets, foreign and domestic, consistent with applicable privacy
laws. This information may include, but is not limited to, information about the applicant's wages,
account balances, investments, insurance policies, benefits, and pensions.
I declare under penalty of perjury that I have examined all the information on this form, and it is true
and correct to the best of my knowledge.
Important: After you submit this application, you will not be able to come back
to it. Check the box next to your name to indicate that you have read and are
signing the statement below.
I, Form Completer, read and agree with the above.
Previous
Submit Now
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs003_YES_SINGLE.html [9/10/2007 7:31:01 AM]
Successful Submission - Print Or Save Your Receipt
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Step:
Complete
Application
Review
Submit
Print
Receipt
Successful Submission - Print Or Save Your Receipt
We recommend that you print or save this page for your records. We have included the exact details
of your submitted application. For instructions on how to print, save, or view the saved file, please
refer to the Print/Save/View Guide.
Select this link to print this page or save it to your computer.
The Application For Help With Medicare Prescription Drug
Plan Costs was received by Social Security on August 23,
2007, 3:38:56 pm.
About You and Your Spouse
You
Name: John Doe
Social Security Number: 743-99-5047
What are your dates of birth? January 1, 1900
Have you worked in 2006 or 2007? Yes
Spouse
Jane Doe
743-99-1047
February 2, 1901
No
Mailing Address: 123 Main Street
Anywhere, SC 34567
We have not changed our address
within the last three months.
Telephone Number: (540) 555-9876
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs004_NO_MARRIED_BOTH.html (1 of 3) [9/10/2007 7:31:02 AM]
Successful Submission - Print Or Save Your Receipt
If your spouse has Medicare (or expects to have Yes
it in the next three months), does he or she also
wish to apply?
Do you have combined savings, investments, No
and real estate worth more than $23,410?
If you would prefer that we contact someone None Provided
else if we have additional questions, please
provide the person's name and a daytime phone
number:
Not counting your spouse, how many other 0
relatives live in your household and receive at
least one-half of their financial support from you
or your spouse?
Do you count on anyone to help pay for any of No
the following household expenses-food,
mortgage, rent, heating fuel or gas, electricity,
water or property taxes?
You
Spouse
Do you or your spouse have any of the following resources:
Combined total of all bank accounts (checking, No
savings and certificates of deposit)
Combined total of all stocks, bonds, savings No
bonds, mutual funds, Individual Retirement
Accounts or other similar investments
Any other cash at home or anywhere else No
Do you or your spouse own life insurance No
policies with a total face value of more than
$1,500?
No
Will some money from any of these sources be
used to pay for funeral or burial expenses?
Other than your home and the property on No
which it is located, do you or your spouse own
any real estate?
You
Spouse
Do you or your spouse receive income from any of the sources listed below:
Social Security benefits
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Successful Submission - Print Or Save Your Receipt
Railroad Retirement income No
No
Veterans benefits No
No
Other pensions and annuities Yes, $500.00
No
per month
Other income not listed, including alimony, net Yes, $500.00
rental income, workers' compensation, etc. per month from
No
Other Income
Has any of the income from these sources No
decreased in the last two years?
You
Spouse
What do you or your spouse expect to earn in Yes, $1,000.00
wages, before taxes and deductions this this year
calendar year?
What do you or your spouse expect your net Yes, net
earnings from self-employment to be this earnings of
calendar year? $1,000.00 this
N/A
year
Have these wages or self-employment earnings No
decreased in the last two years?
Have you or your spouse stopped working in No
2006 or 2007, or plan to stop working in 2007 or
2008?
Continue
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs004_NO_MARRIED_BOTH.html (3 of 3) [9/10/2007 7:31:02 AM]
Successful Submission - Print Or Save Your Receipt
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Step:
Complete
Application
Review
Submit
Print
Receipt
Successful Submission - Print Or Save Your Receipt
We recommend that you print or save this page for your records. We have included the exact details
of your submitted application. For instructions on how to print, save, or view the saved file, please
refer to the Print/Save/View Guide.
Select this link to print this page or save it to your computer.
The Application For Help With Medicare Prescription Drug
Plan Costs was received by Social Security on August 23,
2007, 3:38:07 pm.
About You
Name: John Doe
Social Security Number: 743-99-1047
What is your date of birth? January 1, 1900
Have you worked in 2006 or 2007? Yes
Mailing Address: 123 Main Street
Anywhere, SC 34567
I did not change my address
within the last three months.
Telephone Number: (540) 555-9876
Do you have combined savings, investments, No
and real estate worth more than $11,710?
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs004_NO_SINGLE.html (1 of 3) [9/10/2007 7:31:03 AM]
Successful Submission - Print Or Save Your Receipt
If you would prefer that we contact someone None Provided
else if we have additional questions, please
provide the person's name and a daytime phone
number:
How many relatives live in your household and 0
receive at least one-half of their financial
support from you?
Do you count on anyone to help pay for any of No
the following household expenses-food,
mortgage, rent, heating fuel or gas, electricity,
water or property taxes?
Do you have any of the following resources:
Combined total of all bank accounts (checking, No
savings and certificates of deposit)
Combined total of all stocks, bonds, savings No
bonds, mutual funds, Individual Retirement
Accounts or other similar investments
Any other cash at home or anywhere else No
Do you own life insurance policies with a total No
face value of more than $1,500?
Will some money from any of these sources be
used to pay for funeral or burial expenses?
Other than your home and the property on No
which it is located, do you own any real estate?
Do you receive income from any of the sources listed below:
Social Security benefits
Railroad Retirement income No
Veterans benefits No
Other pensions and annuities No
Other income not listed, including alimony, net No
rental income, workers' compensation, etc.
Has any of the income from these sources No
decreased in the last two years?
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs004_NO_SINGLE.html (2 of 3) [9/10/2007 7:31:03 AM]
Successful Submission - Print Or Save Your Receipt
What do you expect to earn in wages before Yes, $1,500.00 this year
taxes and deductions this calendar year?
What do you expect your net earnings from self- No
employment to be this calendar year?
Have these wages or self-employment earnings No
decreased in the last two years?
Have you stopped working in 2006 or 2007, or Yes, stopped/plan to stop
plan to stop working in 2007 or 2008? February, 2007
Continue
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs004_NO_SINGLE.html (3 of 3) [9/10/2007 7:31:03 AM]
Reentry Number Issued Normal Process
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Step:
Complete
Application
Review
Submit
Print
Receipt
Unsuccessful Submission
We cannot process your request at this time. If you still wish to complete the application, you may:
●
Try again later,
●
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free
TTY number, 1-800-325-0778. Representatives are available Monday through Friday from 7
a.m. to 7 p.m.
Select Exit to leave this application. You will be taken to the Social Security home page.
Exit
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs004_NOT_SUBMITTED.html [9/10/2007 7:31:04 AM]
Next Steps
Skip Navigation Bar
Help With Medicare Prescription
Drug Plan Costs
1-800-772-1213 or TTY 1-800-325-0778, 7am-7pm Monday-Friday
Next Steps
What you just did:
You completed the Application for Help With Medicare Prescription Drug Plan Costs.
What we will do:
We will process your application as quickly as possible. We will contact you if we need more
information. When we finish, we will send a letter to advise whether you qualify for extra help.
What you need to do:
Carefully read the letter we provide. It will say what to do next. Please remember, if you or the
person/people you are helping qualify for this extra help, enrollment in a Medicare prescription drug
plan is required.
If you do not choose a Medicare prescription drug plan, Medicare will select one for you to be sure
this benefit is received. However, if you wait for Medicare to choose, there may be months for which
there is no prescription drug coverage.
For information about prescription drug plans in your area, you may call toll-free 1-800-MEDICARE
(1-800-633-4227) or visit www.medicare.gov. If you are deaf or hard of hearing, you may call the
Medicare TTY number toll-free at 1-877-486-2048.
Exit
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs005.html [9/10/2007 7:31:05 AM]
Missing Information (Fix Errors)
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Help With Medicare Prescription
Drug Plan Costs
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Sign Out (Finish this Later)
Step:
Complete
Application
Need Help?
Review
Submit
Print
Receipt
Missing Information
You must provide the missing information before you can submit this application. To review the
information you entered, select the "Review All Information" button.
Fix This Page
Missing Information: About You And Your Spouse's Living Situation
Fix This Page
Missing Information: Resources
Review All Information
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs006.html [9/10/2007 7:31:05 AM]
Successful Submission - Print Or Save Your Receipt
Successful Submission - Print Or Save Your Receipt
The Application For Help With Medicare Prescription Drug
Plan Costs was received by Social Security on August 23,
2007, 3:38:56 pm.
About You and Your Spouse
You
Name: John Doe
Social Security Number: 743-99-5047
What are your dates of birth? January 1, 1900
Have you worked in 2006 or 2007? Yes
Spouse
Jane Doe
743-99-1047
February 2, 1901
No
Mailing Address: 123 Main Street
Anywhere, SC 34567
We have not changed our address
within the last three months.
Telephone Number: (540) 555-9876
If your spouse has Medicare (or expects to have Yes
it in the next three months), does he or she also
wish to apply?
Do you have combined savings, investments, No
and real estate worth more than $23,410?
If you would prefer that we contact someone None Provided
else if we have additional questions, please
provide the person's name and a daytime phone
number:
Not counting your spouse, how many other 0
relatives live in your household and receive at
least one-half of their financial support from you
or your spouse?
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs007_NO_MARRIED_BOTH.html (1 of 3) [9/10/2007 7:31:06 AM]
Successful Submission - Print Or Save Your Receipt
Do you count on anyone to help pay for any of No
the following household expenses-food,
mortgage, rent, heating fuel or gas, electricity,
water or property taxes?
You
Spouse
Do you or your spouse have any of the following resources:
Combined total of all bank accounts (checking, No
savings and certificates of deposit)
Combined total of all stocks, bonds, savings No
bonds, mutual funds, Individual Retirement
Accounts or other similar investments
Any other cash at home or anywhere else No
Do you or your spouse own life insurance No
policies with a total face value of more than
$1,500?
No
Will some money from any of these sources be
used to pay for funeral or burial expenses?
Other than your home and the property on No
which it is located, do you or your spouse own
any real estate?
You
Spouse
Do you or your spouse receive income from any of the sources listed below:
Social Security benefits
Railroad Retirement income No
No
Veterans benefits No
No
Other pensions and annuities Yes, $500.00
No
per month
Other income not listed, including alimony, net Yes, $500.00
rental income, workers' compensation, etc. per month from
No
Other Income
Has any of the income from these sources No
decreased in the last two years?
You
Spouse
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs007_NO_MARRIED_BOTH.html (2 of 3) [9/10/2007 7:31:06 AM]
Successful Submission - Print Or Save Your Receipt
What do you or your spouse expect to earn in Yes, $1,000.00
wages, before taxes and deductions this this year
calendar year?
What do you or your spouse expect your net Yes, net
earnings from self-employment to be this earnings of
calendar year? $1,000.00 this
N/A
year
Have these wages or self-employment earnings No
decreased in the last two years?
Have you or your spouse stopped working in No
2006 or 2007, or plan to stop working in 2007 or
2008?
Close this window to return to the application.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs007_NO_MARRIED_BOTH.html (3 of 3) [9/10/2007 7:31:06 AM]
Successful Submission - Print Or Save Your Receipt
Successful Submission - Print Or Save Your Receipt
The Application For Help With Medicare Prescription Drug
Plan Costs was received by Social Security on August 23,
2007, 3:38:07 pm.
About You
Name: John Doe
Social Security Number: 743-99-1047
What is your date of birth? January 1, 1900
Have you worked in 2006 or 2007? Yes
Mailing Address: 123 Main Street
Anywhere, SC 34567
I did not change my address
within the last three months.
Telephone Number: (540) 555-9876
Do you have combined savings, investments, No
and real estate worth more than $11,710?
If you would prefer that we contact someone None Provided
else if we have additional questions, please
provide the person's name and a daytime phone
number:
How many relatives live in your household and 0
receive at least one-half of their financial
support from you?
Do you count on anyone to help pay for any of No
the following household expenses-food,
mortgage, rent, heating fuel or gas, electricity,
water or property taxes?
Do you have any of the following resources:
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs007_NO_SINGLE.html (1 of 2) [9/10/2007 7:31:07 AM]
Successful Submission - Print Or Save Your Receipt
Combined total of all bank accounts (checking, No
savings and certificates of deposit)
Combined total of all stocks, bonds, savings No
bonds, mutual funds, Individual Retirement
Accounts or other similar investments
Any other cash at home or anywhere else No
Do you own life insurance policies with a total No
face value of more than $1,500?
Will some money from any of these sources be
used to pay for funeral or burial expenses?
Other than your home and the property on No
which it is located, do you own any real estate?
Do you receive income from any of the sources listed below:
Social Security benefits
Railroad Retirement income No
Veterans benefits No
Other pensions and annuities No
Other income not listed, including alimony, net No
rental income, workers' compensation, etc.
Has any of the income from these sources No
decreased in the last two years?
What do you expect to earn in wages before Yes, $1,500.00 this year
taxes and deductions this calendar year?
What do you expect your net earnings from self- No
employment to be this calendar year?
Have these wages or self-employment earnings No
decreased in the last two years?
Have you stopped working in 2006 or 2007, or Yes, stopped/plan to stop
plan to stop working in 2007 or 2008? February, 2007
Close this window to return to the application.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs007_NO_SINGLE.html (2 of 2) [9/10/2007 7:31:07 AM]
Successful Submission - Print Or Save Your Receipt
Unsuccessful Submission
We cannot process your request at this time. If you still wish to complete the application, you may:
●
Try again later,
●
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free
TTY number, 1-800-325-0778. Representatives are available Monday through Friday from 7
a.m. to 7 p.m.
file:///L|/MMA%20Files/SSA-1020/2007/i1020%20screen%20shots/i1020Complete/rs007_NOT_SUBMITTED.html [9/10/2007 7:31:07 AM]
| File Type | application/pdf |
| File Title | Welcome |
| File Modified | 2007-09-10 |
| File Created | 2007-09-10 |