Form Cms-4040 - Request For Enrollment In Supplementary Medical Insurance Page 2
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2If you are entitled to Medicare’s hospital insurance omit items 5 and 6.
5.
Are you a resident of the United States?
■
■
Yes
No
(To reside in a place means to make a home there.)
6.
a. Are you a citizen of the United States?
■
■
(If “Yes,” omit items b. and c. If “No,” answer b. and c. below.)
Yes
No
■
■
b. Are you lawfully admitted for permanent residence in the United States?
Yes
No
c. Enter below the information requested about your place of residence in the last 5 years.
DATE RESIDENCE
DATE RESIDENCE
ADDRESSES AT WHICH YOU RESIDED IN THE LAST 5 YEARS
BEGAN
ENDED
(Begin with the most recent address. Show actual date residence began
even if that is prior to the last 5 years.)
Month
Day
Year
Month
Day
Year
(If you need more space, use the “Remarks” space or another sheet of paper)
PAYING YOUR PREMIUM
If you sign up for medical insurance, you must pay a premium for each month you have this protection. If you get
monthly Social Security, railroad retirement, or civil service benefits, your premium will be deducted from your
benefit check. If you get none of these benefits, you will be notified how to pay your premium.
The Federal Government contributes to the cost of your insurance. The amount of your premium and the
Government’s payment are based on the cost of services covered by medical insurance. The Government also makes
additional payments when necessary to meet the full cost of the program. (Currently, the Government pays
three-quarters of the cost of this program.) You will get advance notice if there is any change in your premium amount.
Remarks
I know that anyone who makes or causes to be made a false statement or representation of material fact in an application or
for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal law by
fine, imprisonment or both. I affirm that all information I have given in this document is true.
Date (Month, day, year)
SIGNATURE OF APPLICANT
Signature (First name, middle initial, last name) (Write in ink)
Telephone Number
SIGN
HERE
Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)
City
State
ZIP Code
Enter Name of County (if any) in which you now live
Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses
to the signing who know the applicant must sign below, giving their full addresses.
1. Signature of Witness
2. Signature of Witness
Address (Number and street, City, State and ZIP Code)
Address (Number and street, City, State, and ZIP Code)
Form CMS-4040 (8/91)
Page 2
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