Application for Extra Help With Medicare Prescription Drug Plan Costs (field office interview)

ATAI

X Unearned income

Applic.lnt's Name

):; ApplicatIOn Summary

X M!idlore 8~Vil1gs
Progratr,8

X Cont'il~t Inform"tllln

XThird P.rty Info

Spouse's H.lme

S"ollse's $f)ciul Seclllity Numbel'lO#

Who ii apply'"g?
Only you are applying
Both you and your spouse are applying on this application
No! Yel Answered
HIIV9

yon (01 Gpl)lIse If ,"et lnfotlr.atior,
X ThUd Party Inft.

If,.,_ are ananie4 adlilrilll with 1IIvr spoue, do 1IIu kaw ftIiqs, iIMls'lllleJllll, or ~a1 esta. (other tIwt,.,vr
1IInne)_rth_~ tIwt $23,970?

Yes

No

Not Sun

D8111_ (ad,.,. spewe 1f1lllllTJe4 ad JlvbIc 'lDCether) 0IWIl aIlyolthe IiIUawiq
eidler or,.. 0IWIl sepa:n.teq,joiJdly or with UUltherpersoa?
Bulk Al:c8wtlll (CMc:iW'l. saw:bl&s ad c:erdflea.s ofdepmt)

Yes

No

Not Yet AtlBWMed

IfYes, eJl.r the c:ollllWul4lD'Ial value $

Yes

No

Not Yet Answered

IfTes, Ulierthe c:oJlllWlri lD'Ialvalue$
Allyother cult at ko_ or all)'W1tere else

Yes

No

Not Yet AnswMed

IfYes. eJl.r the c:ollllllJle4lD'Ialvalue $

ite_.

bte11lllhl& ~ that

ATIR

Will so_ _ MY &8111. die so_.. UsN _ _ be used 1iI payk tuenl orlnrdal e . _.. ' Ifyos, skip 1iI
die JUl:U qusilaJL Odlerwlse, elder 118.
('*)Ves

ONo

OtbrtJwtyour __ ad teproperty oJlwJdcll ids lecated,_ you OWJI uy real estate? F.u:mples ofoter
real estate are S~r _ _s, rextal pnpertin, or wulJmlloped lud)'Ou 0Wll.
'Yes

(~'No

(:,NotYetAnswered

C1I1TIIJJi Market Value
~onta.::t 1l1fbnnalion

.JTlurd Patty Info

PeneJ.ty of Peljmy

AlIta_tOwed

$0

ATRE

Subsidy Applicatioll
i!.tApplicanllnformation

"No•." Relatives
~ Savings S. iV;courrls
~8Urial&
Real Estate

X Un8amed !nCO!YJ8

X Armiicatio(! SurmYl8
X MeeW;are Savillgs
Progr'ilrns

),: Contact informalion

X Thjn:! Party Into

NOI cOllllting YOIII $POIIS6 If YOII me mauied, how IImny othel leliltiveslive In your household
and lecleve at Ie,,,, olle-hillf oftheit fillmll:i.ll SlIl'POlt flOm YOIl 01 YOIII spouse? We e,)lmt
relallves rel.lted to YOIl by blood. marri.)g& or adoptioll. Do IIOt jm:hld& YOlln~elf 01 yom spouse ill
the .u.llmbel YOII &Illel.

ATUI

De JII. (_ J111II' IlpGuse itmanie4 -1ivUtc 'lllgettter) neeiw! meollle hlll:my ofttte fIIll8wbIg " _ ,

• if Yes. enter the TOTAL MONTHLY INCOME
• if the emount fOf you UId yOU! spouse is combined,

entet the tote! 811\ooot In the field fOt you
• if the emount cbenges from month to month,

enter the AVERAOEMONTHLYlNCOMEfor the past yeufor eacb type
• Do notli8t wages end self-employmen!,interest income, Public Assistance, Medical Reimbutsements or
Foster Care payments here.
RailrtIaa Retire.at Be:neb Befllre De41u:dons

To.

No
:U"'es.~e

Not Yet Answered

_nddy _ _t

''4l:ellq Reporfud AllWwtl $Il

No
If'JII'I.~e

Not Yet Answered

_JItldy_UJtt

,\~eJIC:r Repllrlfd

Ami>lUlt $0

Total RailrNi Retire_lit

Tn

No (::'Not Yet Answered
If'JII'I. aIJ:rap _.'IIdJ-UJtt

l!.lI"""Y Reporu,d Ami>1ll1t $0

Spouse

OYes

No (£iNot Yet Answered

If'yeS.1lI\In&8 _nddy _ _t

AgcJI£y Reported AJIW1ll1t $0

Total Veterus

Yes

No

Not Yet Answered

If'JII'I. -:rap _.dtly _ot

Agency Rep~t1ed AJttoUltt $0

Yes

0 No

Not Yet AnswMed

1i'1I'$.ltI'er.ICe _1dIdy_wtt

AgeJICy Reponed AlIIOllltt $0

Total PellSiollS ud AlUIuities

SIL.-___-'

0tI!er 1IJIeU1lfld hu:o_. hu:J.vdiBc alimeay. llet nmtal hu:elM.werker's eempeJlAtioll,
,ritate or state llIsallill.t;1papullts oil:.
You

Eater _race mollildy_t
AgeJICy Reported Mount $0

Spouse

OY~s ONo

F.1I:ier

NotYrlAnsWMed

-race _Jtildy_wtt

.\1l.em::y Repol1ed Anmunt $0

"1====:;-­

Total OtIulr 1:Ju:o_ - ..

'Ml-_ _---'

Haft anyoftlleso _ t i l deereued IluriJI& tile last tin years?

Not Yet Answered

I Continue 11

Previgus

I[

SelVa and Saturn

ATMS

Yuu Ind)' he able to IJet help fmm )'01/1 stdte with ylllll Medicare ~O$ts undel the Medicdre
SdvillgS PIO!lI.lI1iS. To st,ll1 ),our applicatioll process fOI the Mellicme Savings Plogl.llIlS. SOdill
Secmity will selld infolmatioll frol1l this 'l/Iplic,iltioll to YOIII stilte.unless you teUIIS 1I0t to. "you
KotY6tAnswered

I· COn.tinue ] I Pravi:gus. 11

Save and Seturn

-I

v~w~mr.'" . "
I'MW"ti~~filiL;;~ ~f~$~fufffi~l!y[tWi!~MuJ,-fl~:;#~I;t~1;lni~1T1eir~~~~~rl"'~}f'U~£>"'~i;;: ~

ttvoU ,.«1111)' .......4 WflJlclfl9

tt<>pp• .s Ilt ptltn to ...,.

~f .. 1"11

tn J1nj.l wnddruj ..,.n

.nt., fh. InIJ.'"

stilI )'Uf

,h/tf III'"
.......n l.nch,d.:
fI Coat or drug. and medicall!'9alment fOl AIDS,
fI Ptn"\ironal an.ndenl ..Mel$
fI Wo!4t.ralated nfi.ie1i'tt 'echnol09Y
cene." dePfit¥eion Of 6pllep'J
• VehIcle modifications, dmf neistarlu or
• Guide dog: 8xpenste

other wo!4t·rs!".d UItn'port$1ion need.
• S~lOf1...,d Visual aide

• Whvltlchair
• Srailla Irsl1sl&l:ion$

(,Yes ,~-;:;No ()NotY&tAnswtred

"~","~'R,

'",

,. x~;f~~~
~~"'y ~~2~0'<~~o'~~:

ATTP

It YOII ille ass/stili" someone (Iolse. s(Iol(loct th(lo box that descllbes who JlIIII ille illld
plovid(lo yOUl daytlm(lo mnnb(lol alld .lddlll$ll.
Not Applicable
Family Member
Friend

o Attomey
C) Agency

CAdliocate
() Social Worker

COther

Specify

AssIsting Pelsoll Name

Suffix!

FillIf

Pllone Numllel I
As$istin!j Pelst)n's Adll16$l1

Stleet AddltM

Apintment Nt),

Addlesl! Ulle 3

Adeh eSlIUIltI .. ,

city
Continue

II'----='---

ATeI

Yom PhOIUI Number

S"eet Addre. (
Medicare Savings
Programs

"Contact htfOfmdtlofi
~ Third P3t1\1 Info

ApI,,1ment NQ.

L

Add,e" Line 3
Addte. Line"
CIty,

State

Zill

(To change the address/phone number on the MBR, POS must be used)
If YOII plefel th'lt we cont,lct sOllleone else If we I..we .,ddithlllFile Typeapplication/pdfFile Modified2014-10-07File Created2012-02-14