Form Mc 008 - Qualified Medicare Beneficiary Program Information Notice (Page 2 of 3) in pdf

Form Mc 008 - Qualified Medicare Beneficiary Program Information Notice Page 2

I. Fill in the MONTHLY amounts for the person who wants to be a QMB.

1. Social Security check

2. VA benefits

3. Interest from bank accounts or certificates of deposits

4. Retirement Income

5. Any other Income

6. Total—add lines 1 through 5

II. If you are married and living with your spouse, complete the following MONTHLY

amounts for your spouse even if this spouse also wants to be a QMB.

7. Social Security check

8. VA benefits

9. Interest from bank accounts or certificates of deposit

10. Retirement Income

11. Any Other Income

12. Total—add lines 7 through 11

II. Fill in the MONTHLY amounts for the person in I, and if married, the spouse in II.

13. Gross earnings for the person who wants to be a QMB

14. Gross earnings for the spouse

15. Total—add lines 13 and 14

16. Subtract $65

$ –

17. Remainder

18. Divide by 2

19. Total—add lines 6, 12, and 18

* If you are not married, this tot al cannot exceed $ 908. If you are married and living with your

spouse, this total cannot exceed $ 1,226. However, if you have children or your spouse has

low income, this tot al may be higher. If you received a Title II Social Security cost of

living adjustment, this amount will not be counted until April.

Page 2 of 3

MC 008 Information Notice (10/11)

Form Mc 008 - Qualified Medicare Beneficiary Program Information Notice Page 2