Looking for a Social Security Forms And Templates? Download it for free!

DO NOT COMPLETE THIS IS NOT AN APPLICATION.

Privacy Act / Paperwork Reduction Notice

Section 1860 D-14 of the Social Security Act, as amended, authorizes us to collect this information. We

will use the information you provide to determine if you are eligible for help paying your share of the

cost of a Medicare prescription drug plan.

Furnishing us this information is voluntary. However, failing to provide us with all or part of the

information could prevent us from making an accurate and timely decision on your application.

We rarely use the information you supply for any purpose other than to determine your eligibility for

Extra Help with Medicare Prescription Drug Plan Costs. We may also disclose information to another

person or to another agency in accordance with approved routine uses, which include but are not

limited to the following:

1. To enable a third party or an agency to assist Social Security in establishing rights to Social

Security benefits and/or coverage;

2. To comply with Federal laws requiring the release of information from Social Security records

(e.g., to the Government Accountability Office and Department of Veterans’ Affairs);

3. To make determinations for eligibility in similar health and income maintenance programs at the

Federal, State, and local level; and,

4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity

and improvement of Social Security programs (e.g., to the Bureau of the Census and private

concerns under contract to Social Security).

We may also use the information you provide in computer matching programs. Matching programs

compare our records with records kept by other Federal, State, or local government agencies.

Information from these matching programs can be used to establish or verify a person’s eligibility for

federally-funded or administered benefit programs and for repayment of payments or delinquent debts

under these programs.

A complete list of routine uses for this information are available in Systems of Records Notices entitled,

Master Beneficiary Record, 60-0090, and Medicare Database File, 60-0321. These notices, additional

information regarding this form, and information regarding our programs and systems, are available

on-line at

or at your local Social Security office.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C.

§ 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer

these questions unless we display a valid Office of Management and Budget (OMB) control number.

The OMB control number for this collection is 0960-0696. We estimate that it will take 30 minutes to

read the instructions, gather the facts, and answer the questions. Send only comments relating to our

time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

SEND THE COMPLETED FORM TO US AT THE ADDRESS SHOWN ON THE ENCLOSED

PRE-ADDRESSED, POSTAGE-PAID ENVELOPE:

Social Security Administration

Wilkes-Barre Data Operations Center

P.O. Box 1020

Wilkes-Barre, PA 18767-9910

SSA-1020-INST

Form

(01-2014)

Page 7

Form Ssa-1020-Inst - General Instructions For Completing The Application For Extra Help With Medicare Prescription Drug Plan Costs Page 8

Related Articles

Related forms

Related Categories