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Form Ssa-1020-Inst - General Instructions For Completing The Application For Extra Help With Medicare Prescription Drug Plan Costs Page 3

DO NOT COMPLETE THIS IS NOT AN APPLICATION.

Form Approved

OMB No. 0960-0696

Application for Extra Help with Medicare

FOR OFFICIAL USE ONLY

Prescription Drug Plan Costs

State

WBDOC

THIS IS AN APPLICATION FOR EXTRA HELP AND DOES NOT

Code:

Exception:

ENROLL YOU IN A MEDICARE PRESCRIPTION DRUG PLAN.

1. Applicant’s Name: Print name as it appears on your Social Security card. Use one box for each letter.

FIRST NAME

LAST NAME

SUFFIX (Jr., Sr., etc.)

APPLICANT’S DATE OF BIRTH

APPLICANT’S SOCIAL SECURITY NUMBER

(MM-DD-YYYY)

2. If you are married and living with your spouse, please provide the following information as it

appears on your spouse’s Social Security card. If you are not currently married, do not live with

your spouse or are widowed, skip to question 3 and do not include any information about your

spouse on this application.

FIRST NAME

LAST NAME

SUFFIX (Jr., Sr., etc.)

SPOUSE’S SOCIAL SECURITY NUMBER

SPOUSE’S DATE OF BIRTH

(MM-DD-YYYY)

If your spouse has Medicare, does he or she also wish to apply for the Extra Help?

YES

3. If you are married and live with your spouse, do you have savings, investments or real estate worth

more than $26,860? If you are not married or you do not live with your spouse, is the value more than

$13,440? Do NOT count your home, vehicles, personal possessions, life insurance, burial plots,

irrevocable burial contracts or back payments from Social Security or SSI.

If you place an X in the YES box, you are not eligible for the Extra Help. But,

YES

your State may be able to help you with your Medicare costs through their Medicare

Savings Programs. To start the application process for Medicare Savings Programs,

skip to page 6, sign this application and return it to us. If you are not interested in

Medicare Savings Programs, skip to question 15 on page 5.

If you place an in X the NO or NOT SURE box, complete the rest of this

NO or

application and return it to us.

NOT SURE

SSA-1020-INST

Page 2

Form

(01-2014)

Form Ssa-1020-Inst - General Instructions For Completing The Application For Extra Help With Medicare Prescription Drug Plan Costs Page 3

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