Current SSA-9304

SSA-9304.doc

Medicare Subsidy Quality Review

Current SSA-9304

OMB: 0960-0707

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FORM APPROVED

OMB No. 0960-0707

INFORMATION NEEDED FOR REVIEW OF THE APPLICATION FOR HELP WITH MEDICARE PRESCRIPTION DRUG PLAN COSTS


Please have the INFORMATION CHECKED BELOW on hand for the telephone review. Even if you do not have all of the information that is checked, I will help you get the information you do not have. We only need information about your spouse if you and your spouse were living together when you filed your application.



A. FAMILY SIZE AND HOUSEHOLD EXPENSES INFORMATION

Names, income amount and relationship of any relatives (by blood, marriage or adoption) living with you and your spouse for whom you and/or your spouse provide half of their support.

If you are living with anyone other than your spouse and/or minor children, have their name and amount they contribute towards the household expenses.

The monthly amount you paid for each one of the following items: food, mortgage/ rent, property insurance, property tax, heating fuel, electricity, gas, water, garbage removal and sewer for the time period __________________________________.


B. INCOME

Amount of wages that you or your spouse earned during the period _______________________________________.

The monthly amount of any pensions, or other benefit (other than Social Security benefits) you or your spouse receive.


C. RESOURCES

Balance in bank accounts during the period __________________________ for all accounts on which your name and/or your spouse’s name appear as individual or joint owner, or as a beneficiary.

Value of stocks, bonds, promissory notes, etc. owned by you or your spouse.

Location of property owned by you or your spouse other than the home you live in.

Life insurance and burial insurance policies owned by you or your spouse. (It would be helpful if you have these policies with you when I call, so you can provide the information that I need.)

Amount in retirement savings accounts such as 401K, IRA, KEOGH, etc., owned by you or your spouse.


D. OTHER

__________________________________________________________________

Checklist of Required Information

SSA-9304 (04/2007)

File Typeapplication/msword
File TitleINFORMATION NEEDED FOR REVIEW OF THE APPLICATION FOR HELP WITH MEDICARE PRESCREIPTION DRUG PLAN COSTS
Author232385
Last Modified BySME
File Modified2007-08-13
File Created2007-08-13

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