Instructions SSA-9304

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, we 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 receives.
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.
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 (10-2009)

PRIVACY ACT STATEMENT

Privacy Act Statement
Collection and Use of Personal Information

Section 1860D-14A of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from evaluating the denial of your Medicare Part D subsidy request.
We will use the information to make a determination of eligibility or continued eligibility for
benefits. We may also share your information for the following purposes, called routine uses:
1. To the Centers for Medicare & Medicare Services, for the purpose of administering
Medicare Part D enrollment and premium collection and Medicare Advantage Part C
premium collections, as well as Medicare Part B income-related monthly adjustment
amounts; and
2. To Federal and State agencies administering Medicare Part D and Part D subsidy under
the Medicare Prescription Drug Improvement and Modernization Act of 2003.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0321, entitled Medicare Database File. Additional information and a full listing of
all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.

Checklist of Required Information
SSA-9304 (10-2009)