REDE Field Office Interview

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

Please go to the next page
Form

SSA-1026-OCR-SM-REDE (08-2012) Recycle prior editions

Instructions for Completing the Statement
for Continuing Eligibility for Extra Help
with Medicare Prescription Drug Plan Costs
If You Are Assisting Someone Else With This Form
Answer the questions as if that person were completing the form. You must know that
person’s Social Security number and financial information. Also, complete Section B on
page 6.

How To Complete This Form
• Refer to the Resources and Income Summary on the back of the enclosed letter
when completing this form;
• Use BLACK INK only;
• Keep your numbers, Xs and letters inside the boxes; use only CAPITAL letters;
• Do not add any handwritten comments on the form;
• Do not use dollar signs when entering money amounts. The dollar sign is
preprinted; and
• Cents can be rounded to the nearest whole dollar.
EXAMPLE

EXAMPLE

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

Use capital
letters when
entering answers

A B C D

X
CO R R EC T

I N CO R R EC T

Completing Your Form
Please use the enclosed pre-addressed stamped envelope to return your completed and
signed form to:

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

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

SSA-1026-OCR-SM-REDE (08-2012)

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Form Approved
OMB No. 0960-0723

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

FOR OFFICIAL USE ONLY
State
Code:

WBDOC
Exception:

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

MI
SUFFIX (Jr., Sr., etc.)

LAST NAME
SOCIAL SECURITY NUMBER

DATE OF BIRTH
(MM - DD - YYYY)
EXAMPLE
For January- September put a zero (0) in
the first box. May 20, 1935 should read:

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

0 5 2 0 1 9 3 5

MM DD Y Y Y Y

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

MI

LAST NAME
SPOUSE’S SOCIAL SECURITY NUMBER

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

SPOUSE’S MEDICARE CLAIM NUMBER

3. If your marital status has not changed or you already reported the change to us, go to question 4.
If your marital status has changed and you did not report it to us, what is your current marital status?
Married (living together)
Divorced/Widowed/Separated/Annulled
Form

SSA-1026-OCR-SM-REDE (08-2012)

Date of change in marital status:
Page 2

4. If all of the information on the Resources and Income Summary is correct, place an
and go to question 11 on page 5, sign and return this form.

in the box

If any of the information on the Resources and Income Summary is incorrect, continue to
question 5.
5. We need to know about resources that you, your spouse (if married and living together) or both
of you have.
Instructions: Please look at the information we have about your resources on the Resources and
Income Summary on the back of the enclosed letter.
If the information has not changed, place an in the box and go to question 6.

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

The Correct Amount Is

Bank accounts (checking, savings
and certificates of deposit)
Stocks, bonds, savings bonds, mutual
funds, Individual Retirement Accounts
or other similar investments
Cash

Value of real estate other than your home

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

Form

YOU:

NO

SPOUSE:

NO

SSA-1026-OCR-SM-REDE (08-2012)

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7. For this question, a relative is someone related to you by blood, adoption, or marriage (but not
including your spouse). How many relatives live with you and depend on you or your spouse for
at least one-half of their financial support?
Instructions: Please look at the information we have about your household size on the Resources
and Income Summary on the back of the enclosed letter. If the information has not changed,
place an in the box and go to question 8.

Please do not include yourself or your spouse in the number you enter. If your household
consists only of you or you and your spouse, place an in the ZERO box. Place an in only
one box.
ZERO

1

2

3

4

5

6

7

8

9 or more

8. We need to know about income not from work that you, your spouse (if married and living
together) or both of you have from any of the sources listed below.
Instructions: Please look at the information we have about your income not from work on the
Resources and Income Summary on the back of the enclosed letter.

If the information has not changed, place an

If the information has changed, fill in the new amount in the boxes below.

in the box and go to question 9.

The Correct Monthly Amount Is
Social Security benefits before deductions
Railroad Retirement benefits before deductions
Veteran’s benefits before deductions
Other pensions or annuities before deductions.
Do not include money you receive from
any item you included in question 5.
Other income not listed above, including alimony,
net rental income, workers compensation,
unemployment, private or State disability
payments, etc. (Specify):
Form

SSA-1026-OCR-SM-REDE (08-2012)

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

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

The Correct Annual Amount Is
You

Wages before taxes and deductions

Spouse
You

Net earnings from self-employment

Spouse
You

Net loss from self-employment

Spouse

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

YES

NO

SPOUSE:

YES

NO

11. If you or your spouse (if married and living together) work and plan to stop working, enter
month and year. Otherwise sign the form on page 6 and return it to us.
EXAMPLE
For January – September,
put a zero (0) in the
first box. May 2012
should read:

Form

YOU:

0 5

MM

2 0 1 2
YYYY

SSA-1026-OCR-SM-REDE (08-2012)

Page 5

SPOUSE:

M M

2 0

YYYY

2 0
M M

YYYY

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

Section A
Date:

Your Signature:
Spouse’s Signature:

Phone Number:

Date:

Your Mailing Address:

Apt. #:

City:

State:

Zip Code:

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

Print Last Name:

Phone Number:

Section B
If you are assisting someone else, place an
daytime phone number and address.

in the box that describes who you are and provide your

Family Member

Attorney

Other Advocate

Friend

Agency

Social Worker

Print First Name:

Print Last Name:

Other
Specify:

Phone Number:

Address:

Apt. #:

City:
Form

State:
SSA-1026-OCR-SM-REDE (08-2012)

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Zip Code:

Privacy Act / Paperwork Reduction Notice
Section 1860 D-14 of the Social Security Act authorizes the collection of information
requested on this form. The information you provide will be used to enable the Social
Security Administration (SSA) to determine if you continue to be eligible for help
paying your share of the cost of a Medicare prescription drug plan. You do not have to
give us the information requested. However, if you do not provide the information, we
will be unable to make an accurate and timely decision on your continuing eligibility
for benefits and could result in the loss of your Extra Help with Medicare prescription
drug plan costs. We may provide information collected on this form to another Federal,
State, or local government agency to assist us in determining your initial or continuing
eligibility for the Extra Help or if a Federal law requires the release of the information.
We also may need to share the information with other SSA programs if SSA needs to
determine your eligibility in those programs.
We also may use the information you give us when we match records by computer.
Matching programs compare our records with those of other Federal, State, or local
government agencies. Many agencies may use matching programs to find or prove that
a person qualifies for benefits paid by the Federal government. The law allows us to
do this even if you do not agree to it. Explanations about these and other reasons why
information you provide us may be used or given out are available in Social Security
offices. If you want to learn more about this, contact any Social Security office.
Paperwork Reduction Act Statement — This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 18
minutes to read the instructions, gather the facts, and answer the questions. You may
send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not
the completed form.
SEND THE COMPLETED FORM TO US AT THE ADDRESS SHOWN ON THE
ENCLOSED PRE-ADDRESSED, POSTAGE-PAID ENVELOPE:
Social Security Administration
Wilkes-Barre Data Operations Center
P.O. Box 1080
Wilkes-Barre, PA 18767

Form

SSA-1026-OCR-SM-REDE (08-2012)

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