Form Ssa-1020-Inst - General Instructions For Completing The Application For Extra Help With Medicare Prescription Drug Plan Costs Page 6
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8DO NOT COMPLETE THIS IS NOT AN APPLICATION.
11.
What do you expect your net earnings from self-employment to be this calendar year?
Place an X in the NONE box if you are not self-employed and go to question 12.
YOU:
NONE
$
,
.
SPOUSE:
NONE
$
,
.
Place an X in the box(es) if you or your
SPOUSE:
YOU:
spouse expect a net loss.
12.
Have the amounts you included in questions 10 or 11 decreased in the last two years?
YES
NO
13.
If you or your spouse, stopped working in 2013 or 2014, or plan to stop working in 2014 or 2015,
enter the month and year.
YOU:
M M
Y Y Y Y
SPOUSE:
M M
Y Y Y Y
If you are younger than age 65, answer question 14. If you are married and
living with your spouse and either one of you is younger than age 65,
continue to question 14. Otherwise, skip to question 15.
14.
Do you or your spouse have to pay for things that enable you to work? We will count only a part of
your earnings toward the income limit if you work and receive Social Security benefits based
on a disability or blindness and you have work-related expenses for which you are not reimbursed.
Examples of such expenses are: the cost of medical treatment and drugs for AIDS, cancer,
depression or epilepsy; a wheelchair; personal attendant services; vehicle modifications, driver
assistance or other special work-related transportation needs; work-related assistive technology;
guide dog expenses; sensory and visual aids; and Braille translations.
YOU:
SPOUSE:
YES
NO
YES
NO
15.
Information about Medicare Savings Programs: You may be able to get help from your State
with your Medicare costs under the Medicare Savings Programs. To start your application process
for the Medicare Savings Programs, Social Security will send information from this form to your
State unless you tell us not to. If you want to get help from the Medicare Savings Programs, do
not complete this question. Just sign and date the application and your State will contact you.
If you are not interested in filing for the Medicare Savings Programs, place an X in the box below.
No, do not send the information to the State.
SSA-1020-INST
Page 5
Form
(01-2014)
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