Application For Help With Medicare Prescription Drug Plan Costs - Social Security Administration Page 2
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2We need to know information about your (and your spouse’s, if you’re married and living
together) income and resources:
Resources
Value
Bank accounts, including checking, savings
and certificates of deposit
$ _____________________________________
Stocks, bonds, savings bonds, mutual
funds, individual retirement accounts
(IRAs) or other investments
$ _____________________________________
Cash at home or anywhere else
$ _____________________________________
Life insurance policies for you (and your
spouse, if married and living together)
$ _____________________________________
NOTE: Social Security needs to know how much money you would get if you cashed in
your life insurance policies today. Check with your insurance company or agent to get
the exact cash value. This probably will be less than the amount you are insured for.
Any real estate other than your home
$ _____________________________________
Income
Monthly Amount
Railroad Retirement
$ _____________________________________
Veterans benefits
$ _____________________________________
Other pensions or annuities
$ _____________________________________
Alimony
$ _____________________________________
Net rental income
$ _____________________________________
Workers’ compensation
$ _____________________________________
Help from other people to pay for house-
hold expenses, such as food, mortgage or
rent, heating fuel or gas, electricity, water
and property taxes
$ _____________________________________
Wages
$ _____________________________________
Self-employment net earnings
$ _____________________________________
Other income
$ _____________________________________
You may choose to have someone help you when you do business with Social Security.
We will work with that person, just as we would work with you.
Social Security Administration
SSA Publication No. 05-10128
w w w . s o c i a l s e c u r i t y . g o v
ICN 480068
Unit of Issue - HD (one hundred)
Printed on recycled paper
April 2005
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