Application For Medicare Savings Program (Qmb, Slmb, Qi) Page 3
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APPLICATION FOR MEDICARE SAVINGS PROGRAM
Date of application (month, day, year)
(QMB, SLMB, QI)
State Form 49228 (R5 / 8-11)
Date received by DFR (month, day, year)
1. Tell us about the members of your household. Place a
in the last column if that person is applying. List
applicants, their spouse, their children under age 18, and their children age 18-21 who are students.
Name
Date of Birth
Social Security
Marital
Relationship
Citizen of U.S.
Applying for
Race
Sex
(first, middle initial, last)
Status
to you
(Y / N / ?)
(month, day, year)
Number
Benefits ( )
2. Tell us your address and telephone number
Address (number and street, city, state, and ZIP code)
County
Telephone number
(
)
Mailing address, if different (number and street, city, state, and ZIP code)
County
Other contact number
(
)
Address of authorized representative, if applicable (number and street, city, state, and ZIP code)
County
Telephone number
(
)
□
□
3. Are the applicants residents of Indiana?
Yes
No
□
□
4. Does any applicant have a court-appointed legal guardian?
Yes
No
If yes, who? ______________________________________________________________________________________
In questions 5 and 6, please give information about the household members you listed in question 1, including
the children.
5. Place a
beside the types of income listed below that you and household members receive.
SSI
Unemployment
Cash from friends, relatives, etc.
Social Security
Support (alimony or child support)
Worker’s Compensation
Veteran’s Benefits
Sick benefits / Disability payments
Employment
Income from real estate (such as rent, land contract
Railroad Retirement
Strike pay
payments, farm cash rent payments)
Pension
Interest Payments
Dividends
Military Allotment
Black Lung Benefits
Other? Specify:
□
□
Yes
No
6. Was the household income in the prior three (3) months the same as it is now?
If no, briefly explain: __________________________________________________________________________________________
____________________________________________________________________________________________________________
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Parent category: Medical