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Form Ssa-1021-Inst - Instructions For Completing The Appeal Of Determination For Extra Help With Medicare Prescription Drug Plan Costs Page 2

11. DO YOU NEED AN INTERPRETER?

Check YES and specify the language you prefer and we will provide interpreter services.

Check NO if you do not need an interpreter.

12. ARE YOU HEARING IMPAIRED?

Check YES if you require the use of a telecommunications device for the deaf to

communicate. Check NO if you are not hearing impaired.

13. WILL YOU HAVE OTHER PEOPLE AT THE HEARING?

Check YES if you will have people other than yourself on the telephone conversation.

Check NO if you will not have any other people at the hearing by the telephone. If YES,

will you and the other people need to talk to us from more than one telephone number?

Check YES if you will have people calling in from a telephone number different from

yours. Otherwise, check NO.

SEND THE FORM:

Please return your completed appeal form, including the signature page, and any

additional information to:

Social Security Administration

Wilkes-Barre Data Operations Center

P.O. Box 1030

Wilkes-Barre, PA 18767-1030

SSA-1021-INST

Page 2

Form

(07-2014)

Form Ssa-1021-Inst - Instructions For Completing The Appeal Of Determination For Extra Help With Medicare Prescription Drug Plan Costs Page 2