Form Ssa-1020-Inst - General Instructions For Completing The Application For Extra Help With Medicare Prescription Drug Plan Costs Page 4
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8DO NOT COMPLETE THIS IS NOT AN APPLICATION.
If you placed an X in the NO or NOT SURE box in question 3, answer all of the
following questions. If you are married and living with your spouse, you must
answer all of the questions for both of you.
4.
Enter below money amounts of all bank accounts, investments or cash that you, your spouse, if
married and living together, or both of you own. Also include items that either of you own with
another person. Include only dollar figures not account numbers. If you or your spouse do not own any
item listed, alone or with another person, place an X in the NONE box. Do NOT include a back
payment from Social Security or SSI received in the last 10 months.
•
Combined total of all bank accounts
(checking, savings and certificates
$
NONE
,
.
of deposit)
•
Combined total of all stocks, bonds,
savings bonds, mutual funds,
NONE
$
,
.
Individual Retirement Accounts or
other similar investments
•
Any other cash at home or
$
NONE
,
.
anywhere else
5.
Will some money from the sources listed in question 4 be used to pay for funeral or burial expenses?
If YES, skip to question 6.
If NO, place an X in the NO box, then go to question 6.
YOU:
SPOUSE:
NO
NO
6.
Other than your home and the property on which it is located, do you or your spouse, if married
and living together, own any real estate? Examples of other real estate are summer homes, rental
properties or undeveloped land you own which is separate from your home.
YES
NO
7.
For this question, a relative is someone related to you by blood, adoption, or marriage (but not
including your spouse). How many relatives live with you and depend on you or your spouse for at
least one-half of their financial support?
Please do not include yourself or your spouse in the number you enter. If your household consists
only of you or you and your spouse, place an X in the ZERO box. Place an X in only one box.
ZERO
9 or more
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Page 3
SSA-1020-INST
Form
(01-2014)
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