SSA-1026-REDE - Current Version

SSA-1026 REDE - Current.pdf

Redetermination of Eligibility for Help with Medicare Prescription Drug Plan Costs

SSA-1026-REDE - Current Version

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
amendedbybysection
section2 2ofofthe
thePaperwork
PaperworkReduction
Reduction
Act
Actofof1995.
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Youdodonot
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needtotoanswer
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Wilkes-BarreDirect
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P.O.Box
Box1080
1080
Wilkes-Barre,
Wilkes-Barre,PA
PA18767
18767

Please
Pleasegogototothe
thenext
nextpage
page
SSA-1026-OCR-SM-REDE(08-2020)
(08-2020)
Form
FormSSA-1026-OCR-SM-REDE

Page
Page7 7

Form
FormSSA-1026-OCR-SM-REDE
SSA-1026-OCR-SM-REDE(08-2020)
(08-2020)Recycle
Recycleprior
prioreditions
editions
M051

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SSA-1026-OCR-SM-REDE
SSA-1026-OCR-SM-REDE
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4/28/20 2:32 PM

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

Use capital
letters when
entering answers

A B C D

X
CO R R EC T

Please use the enclosed pre-addressed stamped envelope to return your completed and
signed form to:
Social Security Administration
Wilkes-Barre Direct 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.
SSA-1026-OCR-SM-REDE (08-2020)

Form
Form
SSA-1026-OCR-SM-REDE
SSA-1026-OCR-SM-REDE
(08-2012)
(08-2012)
embedded
embedded
v2_CS5_adjust.indd
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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
Your Signature:
Phone Number:
Date:
Spouse’s Signature:

Date:
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.

I N CO R R EC T

Completing Your Form

Form

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.

Your Mailing Address:

EXAMPLE

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

Signatures
IMPORTANT INFORMATION - PLEASE READ CAREFULLY

Page 1

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 (08-2020)

Zip Code:

Page 6

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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:
Instructions:Please
Pleaselook
lookatatthe
theinformation
informationwewehave
haveabout
aboutyour
yourearned
earnedincome
incomeononthe
the
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

Statement
Statementfor
forContinuing
ContinuingEligibility
Eligibilityfor
forExtra
ExtraHelp
Help
with
withMedicare
MedicarePrescription
PrescriptionDrug
DrugPlan
PlanCosts
Costs
THIS
THISDOES
DOESNOT
NOTENROLL
ENROLLYOU
YOUININAA
MEDICARE
MEDICAREPRESCRIPTION
PRESCRIPTIONDRUG
DRUGPLAN.
PLAN.

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
MEDICARENUMBER
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.
YOU:
YOU:

YES
YES

NO
NO

SPOUSE:
SPOUSE:

YES
YES

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.
EX
EA
XA
MM
PL
PE
LE
For
For
January
January
––
September,
September,
put
put
aa
zero
zero
(0)
(0)
inin
the
the
first
first
box.
box.
May
May
20
20
20
20
should
should
read:
read:

YOU:
YOU:

0 05 5 2 20 02 20 0

MMMM YYYYYYYY

Form
FormSSA-1026-OCR-SM-REDE
SSA-1026-OCR-SM-REDE(08-2020)
(08-2020)

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
MEDICARENUMBER
NUMBER

3.3. IfIfyour
yourmarital
maritalstatus
statushas
hasnot
notchanged
changedororyou
youalready
alreadyreported
reportedthe
thechange
changetotous,us,gogototoquestion
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-REDE(08-2020)
(08-2020)
FormSSA-1026-OCR-SM-REDE

Date
Dateofofchange
changeininmarital
maritalstatus:
status:
Page
Page2 2
M052

Form
Form
SSA-1026-OCR-SM-REDE
SSA-1026-OCR-SM-REDE
(08-2012)
(08-2012)
embedded
embedded
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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-REDE (08-2020)

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-REDE (08-2020)

Page 4

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38496.indd 2

4/28/20 2:52 PM

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-REDE (08-2020)

Page 3

SSA-1026-OCR-SM-REDE (08-2020)

Page 4

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38496.indd 2

4/28/20 2:52 PM

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

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
MEDICARENUMBER
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

YES
YES

NO
NO

SPOUSE:
SPOUSE:

YES
YES

NO
NO

YOU:
YOU:

0 05 5 2 20 02 20 0

MMMM YYYYYYYY

Form
FormSSA-1026-OCR-SM-REDE
SSA-1026-OCR-SM-REDE(08-2020)
(08-2020)

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
MEDICARENUMBER
NUMBER

Date
Dateofofchange
changeininmarital
maritalstatus:
status:
Page
Page2 2
M052

Form
Form
SSA-1026-OCR-SM-REDE
SSA-1026-OCR-SM-REDE
(08-2012)
(08-2012)
embedded
embedded
v2_CS5_adjust.indd
v2_CS5_adjust.indd
5-6 5-6
38496.indd 1

6/8/16
6/8/16
12:24
12:24
PMPM
4/28/20 2:52 PM

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

Use capital
letters when
entering answers

A B C D

X
CO R R EC T

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.
SSA-1026-OCR-SM-REDE (08-2020)

Form
Form
SSA-1026-OCR-SM-REDE
SSA-1026-OCR-SM-REDE
(08-2012)
(08-2012)
embedded
embedded
v2_CS5_adjust.indd
v2_CS5_adjust.indd
3-4 3-4
38495.indd 2

Date:
Apt. #:

City:

State:

Zip Code:

I N CO R R EC T

Completing Your Form

Form

Your Mailing Address:

EXAMPLE

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

Signatures
IMPORTANT INFORMATION - PLEASE READ CAREFULLY

Page 1

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 (08-2020)

Zip Code:

Page 6

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4/28/20 2:32 PM

Statement
Statementfor
forContinuing
ContinuingEligibility
Eligibility
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SSA-1026-OCR-SM-REDE(08-2020)
(08-2020)
Form
FormSSA-1026-OCR-SM-REDE

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Form
FormSSA-1026-OCR-SM-REDE
SSA-1026-OCR-SM-REDE(08-2020)
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