Form Ssa-1020-Inst - General Instructions For Completing The Application For Extra Help With Medicare Prescription Drug Plan Costs Page 7
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8DO 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 application, 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.
Unless I/we answered “No” to Question 15, I am/we are authorizing SSA to disclose to the State the financial
information listed above and other individually identifiable information from my/our file, such as my/our name(s),
date of birth, gender and Social Security number(s) to start the application process for Medicare Savings Programs.
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
Phone Number:
Your Signature:
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 X here:
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 someone assisted you, place an X in the box that describes that person and provide the rest of the
information requested below.
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-1020-INST
Form
(01-2014)
Page 6
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