Form SSA-1026-SCE SSA - Reporting a Change That May Affect Your Extra Help

Redetermination of Eligibility for Help with Medicare Prescription Drug Plan Costs

SSA-1026-SCE - Revised

SSA-1026-SCE - Reporting a Change That May Affect Your Extra Help

OMB: 0960-0723

Document [pdf]

Download: pdf | pdf

Privacy
PrivacyAct
Act/ /Paperwork
PaperworkReduction
ReductionNotice
Notice
Section 1860D-14 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 affect your eligibility for the Medicare Prescription Drug Plan (Part D) subsidy.
We will use the information to review and re-determine your eligibility for the Medicare Part D
subsidy. We may also share your information for the following purposes, called routine uses:
1. To applicants, claimants, prospective applicants or claimants (other than the data subjects
and their authorized representatives) to the extent necessary for the purpose of pursuing
Medicare Part D and Part D subsidy entitlement or appeal rights; and
2. To the Centers for Medicare and Medicaid 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.

Statement
Statementfor
forContinuing
ContinuingEligibility
Eligibility
for
forExtra
ExtraHelp
Helpwith
withMedicare
Medicare
Prescription
PrescriptionDrug
DrugPlan
PlanCosts
Costs

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.ssa.gov/privacy/sorn.html.

Paperwork
PaperworkReduction
ReductionAct
ActStatement
Statement——This
Thisinformation
informationcollection
collectionmeets
meetsthe
the
requirements
requirementsofof4444U.S.C.
U.S.C.§ §3507,
3507,asasamended
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section2 2ofofthe
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Wilkes-BarreDirect
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P.O.
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Box1080
1080
Wilkes-Barre,
Wilkes-Barre,PA
PA18767
18767

Please
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SSA-1026-OCR-SM-SCE(08-2019)
(08-2019)
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Form
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OMBNo.
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0960-0723

9.9. We
Weneed
needtotoknow
knowabout
aboutannual
annualearned
earnedincome
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workthat
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lookatatthe
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haveabout
aboutyour
yourearned
earnedincome
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andIncome
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IfIfthe
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informationhas
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question10.10.
IfIfthe
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informationhas
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boxesbelow.
below.
Type
TypeofofEarned
EarnedIncome
Income
Wages
Wagesbefore
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taxesand
anddeductions
deductions

Net
Netearnings
earningsfrom
fromself-employment
self-employment

Net
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lossfrom
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self-employment

Statement
Statementfor
forContinuing
ContinuingEligibility
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forExtra
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with
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MedicarePrescription
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SSA-1026-OCR-SM-SCE(08-2019)
(08-2019)
Form
FormSSA-1026-OCR-SM-SCE

Page
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3.3. IfIfyour
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Married(living
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Divorced/Widowed/Separated/Annulled
Form
SSA-1026-OCR-SM-SCE(08-2019)
(08-2019)
FormSSA-1026-OCR-SM-SCE

Date
Dateofofchange
changeininmarital
maritalstatus:
status:
Page
Page2 2
M032

Instructions
Instructionsfor
forCompleting
Completingthe
theStatement
Statement
for
forContinuing
ContinuingEligibility
Eligibilityfor
forExtra
ExtraHelp
Help
with
withMedicare
MedicarePrescription
PrescriptionDrug
DrugPlan
PlanCosts
Costs

Signatures
Signatures
IMPORTANT
IMPORTANTINFORMATION
INFORMATION- -PLEASE
PLEASEREAD
READCAREFULLY
CAREFULLY

IfIfYou
YouAre
AreAssisting
AssistingSomeone
SomeoneElse
ElseWith
WithThis
ThisForm
Form

Answer
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Answerthe
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questionsasasif ifthat
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personwere
werecompleting
completingthetheform.
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Youmust
mustknow
know
that person's
person’s
Social Security
andnumber,
financialand
information.
Also, complete Section B on
Social Security
number,number
Medicare
financial information.
page
6. complete Section B on page 6.
Also,

How
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• •Refer
Refertotothe
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I/We
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formand
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Date:
Date:
Apt.
Apt.#:#:

City:
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State:
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preferthat
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Please
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pre-addressedstamped
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envelopetotoreturn
returnyour
yourcompleted
completedand
and
signed
signedform
formto:to:
Social
SocialSecurity
SecurityAdministration
Administration
Wilkes-Barre
Wilkes-BarreDirect
DirectOperations
OperationsCenter
Center
P.O.
P.O.Box
Box1080
1080
Wilkes-Barre,
Wilkes-Barre,PA
PA18767
18767
The
TheResources
Resourcesand
andIncome
IncomeSummary
Summarysheet
sheetononthe
theback
backofofthe
theenclosed
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Print
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IfIfYou
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Form
FormSSA-1026-OCR-SM-SCE
SSA-1026-OCR-SM-SCE(08-2019)
(08-2021)

ByBysubmitting
submittingthis
thisform,
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I am/weare
areauthorizing
authorizingSSA
SSAtotoobtain
obtainand
anddisclose
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informationrelated
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my/ourincome,
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SSA-1026-OCR-SM-SCE(08-2019)
(08-2019)
Form
FormSSA-1026-OCR-SM-SCE

Page
Page1 1

Zip
ZipCode:
Code:

Page
Page6 6

Form
Form
SSA-1026-OCR-SM-SCE
SSA-1026-OCR-SM-SCE
(08-2012)
(08-2012)
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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)

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

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

in the box and go to question 9.

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

Stocks, bonds, savings bonds, mutual
funds, Individual Retirement Accounts
or other similar investments

The Correct Monthly Amount Is
Social Security benefits before deductions

Cash
Railroad Retirement benefits before deductions
Value of real estate other than your home

Veteran’s benefits before deductions

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:

SPOUSE:

SSA-1026-OCR-SM-SCE (08-2019)

Page 3

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-SCE (08-2019)

Page 4

Statement
Statementfor
forContinuing
ContinuingEligibility
Eligibility
for
forExtra
ExtraHelp
Helpwith
withMedicare
Medicare
Prescription
PrescriptionDrug
DrugPlan
PlanCosts
Costs

Please
Pleasegogototothe
thenext
nextpage
page
SSA-1026-OCR-SM-SCE(08-2019)
(08-2019)
Form
FormSSA-1026-OCR-SM-SCE

Form
FormSSA-1026-OCR-SM-SCE
SSA-1026-OCR-SM-SCE(08-2019)
(08-2019)Recycle
Recycleprior
prioreditions
editions

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Page7 7

M031

Form
Form
SSA-1026-OCR-SM-SCE
SSA-1026-OCR-SM-SCE
(08-2012)
(08-2012)
embedded_CS5adjusted.indd
embedded_CS5adjusted.indd
1-2 1-2

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5/12/16
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PMPM

Form
FormApproved
Approved
OMB
OMBNo.
No.0960-0723
0960-0723

Net
Netearnings
earningsfrom
fromself-employment
self-employment

Net
Netloss
lossfrom
fromself-employment
self-employment

YES
YES

State
State
Code:
Code:

WBDOC
WBDOC
Exception:
Exception:

1.1. Name
Name(Print
(Printeach
eachletter
letterinina aseparate
separatebox.)
box.)
MI
MI
SUFFIX
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(JR.,SR.,
SR.,ETC.)
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LAST
LASTNAME
NAME

YOU
YOU
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SOCIAL
SOCIALSECURITY
SECURITYNUMBER
NUMBER

YOU
YOU

DATE
DATEOF
OFBIRTH
BIRTH
(MM
(MM- DD
- DD- YYYY)
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EX
EX
AA
MM
PL
PE
LE

SPOUSE
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For
For
JanuaryJanuarySeptember
September
put
put
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a zero
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the
the
first
first
box.
box.
May
May
20,
20,
1935
1935
should
should
read:
read:

MEDICARE
MEDICARE
CLAIM NUMBER
NUMBER
(This
(Thisnumber
numberisisprinted
printedononyour
yourMedicare
Medicarecard)
card)

YOU
YOU

0 05 5 2 20 0 1 19 93 35 5

MMMMDDDD YYYYYYYY

SPOUSE
SPOUSE

NO
NO

SPOUSE:
SPOUSE:

YES
YES

YOU:
YOU:

EX
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MM
PL
PE
LE

0 0 5 5 2 20 01 19 9

MMMM YYYYYYYY

SSA-1026-OCR-SM-SCE(08-2019)
(08-2019)
Form
FormSSA-1026-OCR-SM-SCE

FOR
FOROFFICIAL
OFFICIAL
USE
USEONLY
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The
TheCorrect
CorrectAnnual
AnnualAmount
AmountIsIs

NO
NO

11.
11.IfIfyou
youororyour
yourspouse
spouse(if(ifmarried
marriedand
andliving
livingtogether)
together)work
workand
andplan
plantotostop
stopworking,
working,enter
enter
month
monthand
andyear.
year.Otherwise
Otherwisesign
signthe
theform
formononpage
page6 6and
andreturn
returnit ittotous.us.
For
For
January
January
––
September,
September,
put
put
aa
zero
zero
(0)
(0)
inin
the
the
first
first
box.
box.
May
May
2019
2019
should
should
read:
read:

THIS
THISDOES
DOESNOT
NOTENROLL
ENROLLYOU
YOUININAA
MEDICARE
MEDICAREPRESCRIPTION
PRESCRIPTIONDRUG
DRUGPLAN.
PLAN.

FIRST
FIRSTNAME
NAME

10.
10.Do
Doyou,
you,your
yourspouse
spouse(if(ifmarried
marriedand
andliving
livingtogether),
together),ororboth
bothhave
havetotopay
payforforthings
thingsthat
thatenable
enable
you
youtotowork
work(also
(alsoknown
knownasasdisability
disabilityororblind
blindwork
workexpenses)?
expenses)?We
Wewill
willcount
countonly
onlya apart
partofof
your
yourearnings
earningstoward
towardthe
theincome
incomelimit
limitif ifyou
youwork
workand
andreceive
receiveSocial
SocialSecurity
Securitybenefits
benefitsbased
basedonon
a adisability
disabilityororblindness
blindnessand
andyou
youhave
havework-related
work-relatedexpenses
expensesforforwhich
whichyou
youare
arenot
notreimbursed.
reimbursed.
Examples
Examplesofofsuch
suchexpenses
expensesare:
are:the
thecosts
costsofofmedical
medicaltreatment
treatmentand
anddrugs
drugsforforAIDS,
AIDS,cancer,
cancer,
depression
depressionororepilepsy;
epilepsy;a awheelchair;
wheelchair;personal
personalattendant
attendantservices;
services;vehicle
vehiclemodifications,
modifications,driver
driver
assistance
assistanceororother
otherspecial
specialwork-related
work-relatedtransportation
transportationneeds;
needs;work-related
work-relatedassistive
assistivetechnology;
technology;
guide
guidedog
dogexpenses;
expenses;sensory
sensoryand
andvisual
visualaids;
aids;and
andBraille
Brailletranslations.
translations.
YOU:
YOU:

Statement
Statementfor
forContinuing
ContinuingEligibility
Eligibilityfor
forExtra
ExtraHelp
Help
with
withMedicare
MedicarePrescription
PrescriptionDrug
DrugPlan
PlanCosts
Costs

Page
Page5 5

SPOUSE:
SPOUSE:

MMMM

2 20 0

YYYYYYYY

2 20 0
MMMM

YYYYYYYY

AND
print your spouse's name as it appears
2.2. Spouse’s
Spouse’sName
Name(If(ifyou
youare
aremarried
married
andliving
livingtogether,
together)
on your spouse's Social Security card. If you are NOT currently married, do NOT live with
your spouse or if you ARE widowed, skip to Question 3).
FIRST NAME
MI
MI

FIRST NAME
LAST NAME
LAST NAME

SUFFIX (JR., SR., ETC.)

SPOUSE’S SOCIAL SECURITY NUMBER
SPOUSE’S SOCIAL SECURITY NUMBER

SUFFIX (JR., SR., ETC.)

SPOUSE’S DATE OF BIRTH
(MM - DD - YYYY)
SPOUSE’S DATE OF BIRTH
(MM - DD - YYYY)

SPOUSE’S MEDICARE CLAIM NUMBER
SPOUSE’S MEDICARE NUMBER
status
has
not
changed
oror
you
reported
thethe
change
toto
us,us,
gogo
toto
question
3.3. If Ifyour
yourmarital
marital
status
has
not
changed
youalready
already
reported
change
question4.4.
IfIfyour
yourmarital
maritalstatus
statushas
haschanged
changedand
andyou
youdid
didnot
notreport
reportit ittotous,us,what
whatisisyour
yourcurrent
currentmarital
maritalstatus?
status?
Married
Married(living
(livingtogether)
together)
Divorced/Widowed/Separated/Annulled
Divorced/Widowed/Separated/Annulled
Form
SSA-1026-OCR-SM-SCE(08-2021)
(08-2019)
FormSSA-1026-OCR-SM-SCE

Date
Dateofofchange
changeininmarital
maritalstatus:
status:
Page
Page2 2
M032

Signatures
Signatures
IMPORTANT
IMPORTANTINFORMATION
INFORMATION- -PLEASE
PLEASEREAD
READCAREFULLY
CAREFULLY

IfIfYou
YouAre
AreAssisting
AssistingSomeone
SomeoneElse
ElseWith
WithThis
ThisForm
Form

Answer
Answerthe
thequestions
questionsasasif ifthat
thatperson
personwere
werecompleting
completingthe
theform.
form.You
Youmust
mustknow
knowthat
that
person’s
person’sSocial
SocialSecurity
Securitynumber
numberand
andfinancial
financialinformation.
information.Also,
Also,complete
completeSection
SectionBBonon
page
page6.6.

How
HowToToComplete
CompleteThis
ThisForm
Form

Use
capital
Use
capital
letters
when
letters
when
entering
answers
entering
answers

AABBCCDD

XX
CO
CO
R R EC
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TT

Date:
Date:
Apt.
Apt.#:#:

City:
City:

State:
State:

Zip
ZipCode:
Code:

I NI N
CO
CO
R R EC
R EC
TT

Completing
CompletingYour
YourForm
Form

Print
PrintFirst
FirstName:
Name:

Print
PrintLast
LastName:
Name:

Phone
PhoneNumber:
Number:

Attorney
Attorney

Other
OtherAdvocate
Advocate

Friend
Friend

Agency
Agency

Social
SocialWorker
Worker

Print
PrintFirst
FirstName:
Name:

Print
PrintLast
LastName:
Name:

Other
Other
Specify:
Specify:
Phone
PhoneNumber:
Number:

Address:
Address:

IfIfYou
YouHave
HaveQuestions
QuestionsOr
OrNeed
NeedHelp
HelpCompleting
CompletingThis
ThisForm
Form

Your
YourMailing
MailingAddress:
Address:

EX
EX
AA
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LE

Put
Put
an
an
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inin
the
the
box.
box.
DO
DO
NOT
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fill
fill
inin
oror
use
use
check
check
marks
marks
inin
boxes.
boxes.

Apt.
Apt.#:#:

City:
City:

State:
State:

SSA-1026-OCR-SM-SCE(08-2019)
(08-2019)
Form
FormSSA-1026-OCR-SM-SCE

Page
Page1 1

Zip
ZipCode:
Code:

Page
Page6 6

Form
Form
SSA-1026-OCR-SM-SCE
SSA-1026-OCR-SM-SCE
(08-2012)
(08-2012)
embedded_CS5adjusted.indd
embedded_CS5adjusted.indd
3-4 3-4

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PMPM

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

in the
the box
box
in

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
have.
of you have.
Instructions: Please
Instructions:
Please look
look at
at the
the information
information we
we have
have about your resources on the Resources and
Income Summary
on theSummary
back of the
enclosed
letter.
Resources
and Income
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)

If the information has not changed, place an

9 or more

in the box and go to question 9.

The Correct Monthly Amount Is

Cash
Railroad Retirement benefits before deductions
Value of real estate other than your home

Veteran’s benefits before deductions

6. Will some money from the sources listed in question 5 be used to pay for funeral or burial expenses?
If YES, skip to
Instructions:
If question
YES, skip7.to question 7.
place
anbox,
inthen
the NO
then go
in the
NO
go tobox,
question
7. to question 7.
If NO, place anIf NO,
Do NOT place an in the spouse NO box if you did not provide spouse information in Question 2.
YOU:
NO

(08-2019)
SSA-1026-OCR-SM-SCE (08-2021)

Social Security benefits before deductions

Form

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

Stocks, bonds, savings bonds, mutual
funds, Individual Retirement Accounts
or other similar investments

SPOUSE:

NO
Page 3

SSA-1026-OCR-SM-SCE (08-2019)

Page 4

Signatures
Signatures
IMPORTANT
IMPORTANTINFORMATION
INFORMATION- -PLEASE
PLEASEREAD
READCAREFULLY
CAREFULLY

IfIfYou
YouAre
AreAssisting
AssistingSomeone
SomeoneElse
ElseWith
WithThis
ThisForm
Form

How
HowToToComplete
CompleteThis
ThisForm
Form

Use
capital
Use
capital
letters
when
letters
when
entering
answers
entering
answers

AABBCCDD

XX
CO
CO
R R EC
R EC
TT

Date:
Date:
Apt.
Apt.#:#:

City:
City:

State:
State:

Zip
ZipCode:
Code:

I NI N
CO
CO
R R EC
R EC
TT

Completing
CompletingYour
YourForm
Form

Print
PrintFirst
FirstName:
Name:

Print
PrintLast
LastName:
Name:

Phone
PhoneNumber:
Number:

Attorney
Attorney

Other
OtherAdvocate
Advocate

Friend
Friend

Agency
Agency

Social
SocialWorker
Worker

Print
PrintFirst
FirstName:
Name:

Print
PrintLast
LastName:
Name:

Other
Other
Specify:
Specify:
Phone
PhoneNumber:
Number:

Address:
Address:

IfIfYou
YouHave
HaveQuestions
QuestionsOr
OrNeed
NeedHelp
HelpCompleting
CompletingThis
ThisForm
Form

Your
YourMailing
MailingAddress:
Address:

EX
EX
AA
MM
PL
PE
LE

Put
Put
an
an
XX
inin
the
the
box.
box.
DO
DO
NOT
NOT
fill
fill
inin
oror
use
use
check
check
marks
marks
inin
boxes.
boxes.

Apt.
Apt.#:#:

City:
City:

State:
State:

SSA-1026-OCR-SM-SCE(08-2019)
(08-2019)
Form
FormSSA-1026-OCR-SM-SCE

Page
Page1 1

Zip
ZipCode:
Code:

Page
Page6 6

Form
Form
SSA-1026-OCR-SM-SCE
SSA-1026-OCR-SM-SCE
(08-2012)
(08-2012)
embedded_CS5adjusted.indd
embedded_CS5adjusted.indd
3-4 3-4

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5/12/16
3:273:27
PMPM

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 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)

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:
Pleaselook
lookatatthe
theinformation
informationwe
wehave
haveabout
about your
your household
household size
size on
on the Resources
Instructions: Please
Resources
and
Income
Summary
on
the
back
of
the
enclosed
letter.
If
the
information
has not
and Income Summary on the back of the enclosed letter. If the information has not changed,
changed,
anboxin
place an place
thegobox
and go to8.question 8.
in the
and
to question
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

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
of you
you have
have from
from any
any of
ofthe
thesources
sourceslisted
listedbelow.
below.
Instructions:
Instructions: Please
Please look
look at
at the
the information
information we
we have
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

in the box and go to question 9.

If the information has changed, fill in the new amount in the boxes below. If you or your spouse
If the information
has
changed,
fill listed
in thebelow,
new amount
in theinboxes
below. box for that source.
receive
zero income
from
a source
place an
the NONE

Stocks, bonds, savings bonds, mutual
funds, Individual Retirement Accounts
or other similar investments

The
TheCorrect
CorrectMonthly
MonthlyAmount
AmountIsIs
Social Security benefits before deductions

NONE

Railroad
RailroadRetirement
Retirementbenefits
benefitsbefore
beforedeductions
deductions

NONE

Veteran’s benefits before deductions

NONE

Other pensions or annuities before deductions.
Do not include money you receive from
any item you included in question 5.

NONE

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:

SPOUSE:

SSA-1026-OCR-SM-SCE (08-2019)

Page 3

Other income not listed above, including alimony,
net
rentalnet
income,
alimony,
rentalworkers
income,compensation,
workers
NONE
unemployment,
private or Stateprivate
disability
compensation, unemployment,
or State
payments,
etc. (Specify):
disability payments,
etc. (Specify):
Form

SSA-1026-OCR-SM-SCE (08-2019)
(08-2021)

Page 4

Statement
Statementfor
forContinuing
ContinuingEligibility
Eligibility
for
forExtra
ExtraHelp
Helpwith
withMedicare
Medicare
Prescription
PrescriptionDrug
DrugPlan
PlanCosts
Costs

Please
Pleasegogototothe
thenext
nextpage
page
SSA-1026-OCR-SM-SCE(08-2019)
(08-2019)
Form
FormSSA-1026-OCR-SM-SCE

Form
FormSSA-1026-OCR-SM-SCE
SSA-1026-OCR-SM-SCE(08-2019)
(08-2019)Recycle
Recycleprior
prioreditions
editions

Page
Page7 7

M031

Form
Form
SSA-1026-OCR-SM-SCE
SSA-1026-OCR-SM-SCE
(08-2012)
(08-2012)
embedded_CS5adjusted.indd
embedded_CS5adjusted.indd
1-2 1-2

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PMPM

Form
FormApproved
Approved
OMB
OMBNo.
No.0960-0723
0960-0723

9.9. We
Weneed
needtotoknow
knowabout
aboutannual
annualearned
earnedincome
incomefrom
fromwork
workthat
thatyou,
you,your
yourspouse
spouse(if(ifmarried
married
and
andliving
livingtogether)
together)ororboth
bothofofyou
youhave.
have.
Instructions:Please
Pleaselook
lookatatthe
theinformation
informationwe
wehave
haveabout
aboutyour
yourearned
earnedincome
incomeon
onthe
the
Instructions:
Resources
Resourcesand
andIncome
IncomeSummary
Summaryononthe
theback
backofofthe
theenclosed
enclosedletter.
letter.
IfIfthe
theinformation
informationhas
hasnot
notchanged,
changed,place
placeanan ininthe
thebox
boxand
andgogototoquestion
question10.10.
IfIfthe
theinformation
informationhas
haschanged,
changed,fillfillininthe
thenew
newamount
amountininthe
theboxes
boxesbelow.
below.
Type
TypeofofEarned
EarnedIncome
Income
Wages
Wagesbefore
beforetaxes
taxesand
anddeductions
deductions

Net
Netearnings
earningsfrom
fromself-employment
self-employment

Net
Netloss
lossfrom
fromself-employment
self-employment

FOR
FOROFFICIAL
OFFICIAL
USE
USEONLY
ONLY
State
State
Code:
Code:

WBDOC
WBDOC
Exception:
Exception:

1.1. Name
Name(Print
(Printeach
eachletter
letterinina aseparate
separatebox.)
box.)
FIRST
FIRSTNAME
NAME

MI
MI

The
TheCorrect
CorrectAnnual
AnnualAmount
AmountIsIs
SUFFIX
SUFFIX(JR.,
(JR.,SR.,
SR.,ETC.)
ETC.)

LAST
LASTNAME
NAME

YOU
YOU
SPOUSE
SPOUSE

SOCIAL
SOCIALSECURITY
SECURITYNUMBER
NUMBER

YOU
YOU

DATE
DATEOF
OFBIRTH
BIRTH
(MM
(MM- DD
- DD- YYYY)
- YYYY)
EX
EX
AA
MM
PL
PE
LE

SPOUSE
SPOUSE

For
For
JanuaryJanuarySeptember
September
put
put
a zero
a zero
(0)
(0)
inin
the
the
first
first
box.
box.
May
May
20,
20,
1935
1935
should
should
read:
read:

MEDICARE
MEDICARECLAIM
CLAIMNUMBER
NUMBER
(This
(Thisnumber
numberisisprinted
printedononyour
yourMedicare
Medicarecard)
card)

YOU
YOU

0 05 5 2 20 0 1 19 93 35 5

MMMMDDDD YYYYYYYY

SPOUSE
SPOUSE

2.2. Spouse’s
Spouse’sName
Name(if(ifyou
youare
aremarried
marriedand
andliving
livingtogether)
together)
10.
10.Do
Doyou,
you,your
yourspouse
spouse(if(ifmarried
marriedand
andliving
livingtogether),
together),ororboth
bothhave
havetotopay
payforforthings
thingsthat
thatenable
enable
you
youtotowork
work(also
(alsoknown
knownasasdisability
disabilityororblind
blindwork
workexpenses)?
expenses)?We
Wewill
willcount
countonly
onlya apart
partofof
your
yourearnings
earningstoward
towardthe
theincome
incomelimit
limitif ifyou
youwork
workand
andreceive
receiveSocial
SocialSecurity
Securitybenefits
benefitsbased
basedonon
a adisability
disabilityororblindness
blindnessand
andyou
youhave
havework-related
work-relatedexpenses
expensesforforwhich
whichyou
youare
arenot
notreimbursed.
reimbursed.
Examples
Examplesofofsuch
suchexpenses
expensesare:
are:the
thecosts
costsofofmedical
medicaltreatment
treatmentand
anddrugs
drugsforforAIDS,
AIDS,cancer,
cancer,
depression
depressionororepilepsy;
epilepsy;a awheelchair;
wheelchair;personal
personalattendant
attendantservices;
services;vehicle
vehiclemodifications,
modifications,driver
driver
assistance
assistanceororother
otherspecial
specialwork-related
work-relatedtransportation
transportationneeds;
needs;work-related
work-relatedassistive
assistivetechnology;
technology;
guide
guidedog
dogexpenses;
expenses;sensory
sensoryand
andvisual
visualaids;
aids;and
andBraille
Brailletranslations.
translations.
Instructions: If NO, skip to question 11. If YES, place an in the YES box then go to Question 11.
Do NOT
fill in theYES
boxes nextNO
to SPOUSE if you did
not put spouse
information
in Question 2.
YOU:
SPOUSE:
YES
NO
YOU:
YES
YES
SPOUSE:
If
you
or
your
spouse
(if
married
and
living
together)
work
and
plan
stopworking,
working,enter
enter
11.
11.If you or your spouse (if married and living together) work and plan totostop
monthand
andyear.
year.Otherwise
Otherwisesign
signthe
theform
formononpage
page6 6and
andreturn
returnit ittotous.us.
month
Do NOT fill in the boxes next to SPOUSE if you did not put spouse information in Question 2.
YOU:
YOU:

EA
XA
PE
LE
EX
MM
PL
For
For
January
January
––
September,
September,
put
zero
(0)ininthe
the
put
aa
zero
(0)
first
box.
May
2021
first
box.
May
2019
should
read:
should
read:

0 05 5 2 2 0 0 1 2 9 1

MMMM YYYYYYYY

(08-2021)
SSA-1026-OCR-SM-SCE(08-2019)
Form
FormSSA-1026-OCR-SM-SCE

Page
Page5 5

SPOUSE:
SPOUSE:

MMMM

2 20 0

YYYYYYYY

2 20 0
MMMM

YYYYYYYY

FIRST
FIRSTNAME
NAME

MI
MI

LAST
LASTNAME
NAME

SUFFIX
SUFFIX(JR.,
(JR.,SR.,
SR.,ETC.)
ETC.)

SPOUSE’S
SPOUSE’SSOCIAL
SOCIALSECURITY
SECURITYNUMBER
NUMBER

SPOUSE’S
SPOUSE’SDATE
DATEOF
OFBIRTH
BIRTH
(MM
(MM- DD
- DD- YYYY)
- YYYY)

SPOUSE’S
SPOUSE’SMEDICARE
MEDICARECLAIM
CLAIMNUMBER
NUMBER

Date
Dateofofchange
changeininmarital
maritalstatus:
status:
Page
Page2 2
M032

Signatures
Signatures
IMPORTANT
IMPORTANTINFORMATION
INFORMATION- -PLEASE
PLEASEREAD
READCAREFULLY
CAREFULLY

IfIfYou
YouAre
AreAssisting
AssistingSomeone
SomeoneElse
ElseWith
WithThis
ThisForm
Form

How
HowToToComplete
CompleteThis
ThisForm
Form

Use
capital
Use
capital
letters
when
letters
when
entering
answers
entering
answers

AABBCCDD

XX
CO
CO
R R EC
R EC
TT

Date:
Date:
Apt.
Apt.#:#:

City:
City:

State:
State:

Zip
ZipCode:
Code:

I NI N
CO
CO
R R EC
R EC
TT

Completing
CompletingYour
YourForm
Form

Print
PrintFirst
FirstName:
Name:

Print
PrintLast
LastName:
Name:

Phone
PhoneNumber:
Number:

Attorney
Attorney

Other
OtherAdvocate
Advocate

Friend
Friend

Agency
Agency

Social
SocialWorker
Worker

Print
PrintFirst
FirstName:
Name:

Print
PrintLast
LastName:
Name:

Other
Other
Specify:
Specify:
Phone
PhoneNumber:
Number:

Address:
Address:

IfIfYou
YouHave
HaveQuestions
QuestionsOr
OrNeed
NeedHelp
HelpCompleting
CompletingThis
ThisForm
Form

Your
YourMailing
MailingAddress:
Address:

EX
EX
AA
MM
PL
PE
LE

Put
Put
an
an
XX
inin
the
the
box.
box.
DO
DO
NOT
NOT
fill
fill
inin
oror
use
use
check
check
marks
marks
inin
boxes.
boxes.

Apt.
Apt.#:#:

City:
City:

State:
State:

SSA-1026-OCR-SM-SCE(08-2021)
(08-2019)
FormSSA-1026-OCR-SM-SCE
Form

Page
Page1 1

Zip
ZipCode:
Code:

Page
Page6 6

Form
Form
SSA-1026-OCR-SM-SCE
SSA-1026-OCR-SM-SCE
(08-2012)
(08-2012)
embedded_CS5adjusted.indd
embedded_CS5adjusted.indd
3-4 3-4

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5/12/16
3:273:27
PMPM

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 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)

9 or more

in the box and go to question 9.

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

Stocks, bonds, savings bonds, mutual
funds, Individual Retirement Accounts
or other similar investments

The Correct Monthly Amount Is
Social Security benefits before deductions

Cash
Railroad Retirement benefits before deductions
Value of real estate other than your home

Veteran’s benefits before deductions

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:

SPOUSE:

SSA-1026-OCR-SM-SCE (08-2019)

Page 3

SSA-1026-OCR-SM-SCE (08-2019)

Page 4

See Revised Privacy Act &
PRA Statements attached

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meets
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(08-2021)
SSA-1026-OCR-SM-SCE(08-2019)
Form
FormSSA-1026-OCR-SM-SCE

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SSA-1026-OCR-SM-SCE(08-2019)
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M032

SSA will insert the following revised Privacy Act & PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Section 1860D-14 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 affect your eligibility for the Medicare Prescription Drug Plan (Part D) subsidy.
We will use the information you provide to review and re-determine your eligibility for the
Medicare Part D subsidy. We may also share the information for the following purposes, called
routine uses:
•

To applicants, claimants, prospective applicants or claimants (other than the data
subjects and their authorized representatives) to the extent necessary for the purpose
of pursuing Medicare Part D and Part D subsidy entitlement or appeal rights; and

•

To the Centers for Medicare and Medicaid 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.

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 Notices
(SORNs) 60-0310, entitled Medicare Savings Programs Information System, as published in the
Federal Register (FR) on March 31, 2004, at 69 FR 17019; and 60-0321, entitled Medicare
Database (MDB) File, as published in the FR on July 25, 2006, at 71 FR 42159. Additional
information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.

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
(OMB) control number. We estimate that it will take about 18 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments regarding this burden estimate
or any other aspect of this collection, including suggestions for reducing this burden to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.

File Type	application/pdf
File Modified	2021-03-08
File Created	2020-11-10