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Form Ssa-1020-Inst - General Instructions For Completing The Application For Extra Help With Medicare Prescription Drug Plan Costs Page 2

DO NOT COMPLETE THIS IS NOT AN APPLICATION.

General Instructions for Completing the

Application for Extra Help with Medicare

Prescription Drug Plan Costs

If You Are Assisting Someone Else With This Application

Answer the questions as if that person were completing the application. You must know that person’s

Social Security number and financial information. Also, complete Section B on page 6.

Do you have Medicare and Supplemental Security Income (SSI) or Medicare and Medicaid?

If the answer is YES, do not complete this application because you automatically will get the

Extra Help.

Does your State Medicaid program pay your Medicare premiums because you belong to a

Medicare Savings Program?

If the answer is YES, contact your State Medicaid office for more information. You could get the

Extra Help automatically and may not need to complete this application.

How To Complete This Application

• Use BLACK INK only;

• Keep your numbers, letters and Xs inside the boxes; use only CAPITAL letters;

• Do not add any handwritten comments on the application;

• Do not use dollar signs when entering money amounts; and

• Cents can be rounded to the nearest whole dollar.

Completing Your Application

You may complete the online application at

or use the enclosed

pre-addressed stamped envelope to return your completed and signed application to:

Social Security Administration

Wilkes-Barre Data Operations Center

P.O. Box 1020

Wilkes-Barre, PA 18767-9910

Return this application package in the enclosed envelope. Do not include anything else in the envelope.

If we need more information, we will contact you.

NOTE: To apply, you must live in one of the 50 States or the District of Columbia.

If You Have Questions Or Need Help Completing This Application

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-1020-INST

Page 1

Form

(01-2014)

Form Ssa-1020-Inst - General Instructions For Completing The Application For Extra Help With Medicare Prescription Drug Plan Costs Page 2