Form Ssa-1026b-Ocr-Sm-Inst - Statement Foe Continuing Eligibility For Extra Help With Medicare Prescription Drug Plan Costs Page 9
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10DO NOT COMPLETE. THIS IS NOT AN APPLICATION.
Signatures
IMPORTANT INFORMATION - PLEASE READ CAREFULLY
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.
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:
Your Mailing Address:
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.
Print First Name:
Print Last Name:
Phone Number:
Section B
If you are assisting someone else, place an
in the box that describes who you are and provide your
daytime phone number and address.
Other
Family Member
Attorney
Other Advocate
Specify:
Friend
Agency
Social Worker
Print First Name:
Print Last Name:
Phone Number:
Address:
Apt. #:
City:
State:
Zip Code:
SSA-1026B-OCR-SM-INST
Page 6
Form
(08-2012)
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