Form Ssa-1026b-Ocr-Sm-Inst - Statement Foe Continuing Eligibility For Extra Help With Medicare Prescription Drug Plan Costs Page 6
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10DO NOT COMPLETE. THIS IS NOT AN APPLICATION.
4. If all of the information on the Resources and Income Summary is correct, place an
in the box
and go to question 11 on page 5, sign and return this form.
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)
Stocks, bonds, savings bonds, mutual
funds, Individual Retirement Accounts
or other similar investments
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.
YOU:
NO
SPOUSE:
NO
SSA-1026B-OCR-SM-INST
Page 3
Form
(08-2012)
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