Social Security Administration Important Information

Transcription

1 Social Security Aministration Important Information THIS COVER LETTER IS FOR INFORMATION ONLY. DO NOT COMPLETE THE FOLLOWING PAGES. THIS IS NOT AN APPLICATION. You may be eligible to get Extra Help paying for your prescription rugs. The Meicare Prescription Drug program gives you a choice of prescription plans that offer various types of coverage. In aition, you may be able to get Extra Help to pay for the monthly premiums, annual euctibles, an co-payments relate to the Meicare Prescription Drug program. But before we can help you, you must fill out this application, put it in the enclose envelope an mail it toay. Or you may complete an online application at We will review your application an sen you a letter to let you know if you qualify for Extra Help. To use the Extra Help, you must enroll in a Meicare Prescription Drug plan. If you nee help completing the application, call Social Security at (TTY ). You can fin more information at You also may be able to get help from your state with other Meicare costs uner the Meicare Savings Programs. By completing this form, you will start your application process for a Meicare Savings Program. We will sen information to your state who will contact you to help you apply for a Meicare Savings Program unless you tell us not to by answering question 15 on this form. If you nee information about Meicare Savings Programs, Meicare Prescription Drug plans or how to enroll in a plan, call MEDICARE (TTY ) or visit You also can request information about how to contact your State Health Insurance Assistance Program (SHIP). The SHIP offers help with your Meicare questions. Please mail your application toay. Michael J. Astrue Commissioner!"#$%&&'()*+*,(-./(&0(12&3%4)+(+**56%789:#";%<#="#%8>=:="?9

2 General Instructions for Completing the Application for Extra Help with Meicare Prescription Drug Plan Costs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lace an X in the box. DO NOT fill in or use check marks in boxes. C CORRECT INCORRECT EXAMPLE Use capital letters when entering answers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

3 Application for Extra Help with Meicare Prescription Drug Plan Costs 5E!/#!/#'M#'GGK!I'5!RM#^R_#1N5_'#E1KG#'M9#9R1/#MR5# 1M_RKK#$R`#!M#'#<19!I'_1#G_1/I_!G5!RM#9_`a#GK'MF SF'!003,1."(8#'N.2%I'O&,"('".2%'8*#+,#866)8(*#%-#:%&(#/%7+82#/)7&(+,:#78(=5'C#%'-"%';-P'/-&'%.1)'3%((%&5 ^!_/5#M'<1 <! K'/5#M'<1 /`^^!N#>b(FA#/(FA#),7F? 'GGK!I'M5c/#/RI!'K#/1I`_!5$#M`<J1_ 'GGK!I'M5c/#9'51#R^#J!_5E## ><<Q99Q$$$$? UF' A/':-+'.&%'08((+)=#8-=#2+;+-.#C+,4#:%&(#*6%&*)>'03%.#%'0&-H,<%'()%'/-33-$,"4',"/-&2.(,-"'8*#+,# 866)8(*#%-#:%&(#*6%&*)c*#/%7+82#/)7&(+,:#78(=5'A/':-+'.&%'"-('1+&&%"(3:'2.&&,%<>'<-'"-('3,H%'$,()' :-+&'#0-+#%'-&'.&%'$,<-$%<>'#7,0'(-'*+%#(,-"'Q'."<'<-'"-(',"13+<%'.":',"/-&2.(,-"'.;-+(':-+&' #0-+#%'-"'(),#'.003,1.(,-"5 ^!_/5#M'<1 <! K'/5#M'<1 /`^^!N#>b(FA#/(FA#),7F? /GR`/1c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`_1!"#:%&#6287)#8- +-#,4)#$1/#B%DA#:%&#8()#-%,#)2+.+B2)#"%(#,4)#1D,(8#E)265'?+(>':-+&' #(.(%'2.:';%'.;3%'(-')%30':-+'$,()':-+&'R%<,1.&%'1-#(#'()&-+4)'()%,&'R%<,1.&%'9.H,"4#' O&-4&.2#5'K-'#(.&('()%'.003,1.(,-"'0&-1%##'/-&'R%<,1.&%'9.H,"4#'O&-4&.2#>'#7,0'(-' 9.H,"4#'O&-4&.2#>'#7,0'(-'*+%#(,-"'XL'-"'0.4%'L5!"#:%&#6287)#8-# #+-#,4)#MR#%(#MR5#/`_1';-P>'1-203%(%'()%'&%#('-/'(),#'.003,1.(,-"'."<'&%(+&"',('(-'+#5

4 If you place an in the NO or NOT SURE box in question 3, answer all of the following questions. If you are marrie an living with your spouse, you must answer all of the questions for both of you. ef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f&)*,+%-#e#;%'+#%<'(-'0.:'/-&'/+"%&.3'-&';+&,.3'%P0%"#%#U' #!"#$1/A#*P+6#,%#f&)*,+%-#XF # A/'MR>'03.1%'."' ',"'()%'MR';-P>'()%"'4-'(-'*+%#(,-"'@5 $R`Z MR /GR`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e ] X W V Y#%(#0%()!"#$%&&'()*+*,(-./(&0(12&3%4)+(+**56%@AB8%D

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`'<%1&%.#%<'<+&,"4'()%'3.#('($-':%.&#U $1/ MR If you have worke in the last two years, you nee to answer questions If you are marrie an living with your spouse an either one of you has worke in the last two years, you nee to answer questions Otherwise, skip to question 15. STF' [).('<-':-+'%P0%1('(-'%.&"',"'$.4%#';%/-&%'(.P%#'."<'<%<+1(,-"#',4+*#782)-=8(#:)8(U $R`Z

6 SSF' [).('<-':-+'%P0%1(':-+&'"%('%.&","4#'/&-2'#%3/G%203-:2%"('(-';%',4+*#782)-=8(#:)8(U' O3.1%'."' ',"'()%'';-P',/':-+'.&%'"-('#%3/G%203-:%<'."<'4-'(-'*+%#(,-"'XW5 $R`Z /GR`/1Z ' O3.1%'."' ',"'()%';-PY%#Z',/':-+'-&':-+&' #0-+#%'%P0%1('.'"%('3-##5'' $R`Z /GR`/1Z SUF' T.H%'()%'.2-+"(#':-+',"13+<%<',"'*+%#(,-"#'XM'-&'XX'<%1&%.#%<',"'()%'3.#('($-':%.&#U' $1/ MR S\F' A/':-+'-&':-+&'#0-+#%>'#(-00%<'$-&7,"4',"'WMMa'-&'WMXM>'-&'03."'(-'#(-0'$-&7,"4',"'WMXM'-&'WMXX>' %"(%&'()%'2-"()'."<':%.&5 $R`Z W M EXAMPLE < < $ $ $ $ For January September, place a zero (0) in the first box. May 2010 shoul rea: M L W M X M < < $ $ $ $ /GR`/1Z W M < < $ $ $ $ If you are younger than age 65, answer question 14. If you are marrie an living with your spouse an either one of you is younger than age 65, continue to question 14. Otherwise, skip to question 15. Se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`Z $1/ MR /GR`/1Z $1/ MR S]F'!-"%(08,+%-#8B%&,#<)=+78()#/8;+-.*#G(%.(80*Z'6-+'2.:';%'.;3%'(-'4%(')%30'/&-2':-+&'#(.(%' $,()':-+&'R%<,1.&%'1-#(#'+"<%&'()%'R%<,1.&%'9.H,"4#'O&-4&.2#5'K-'#(.&(':-+&'.003,1.(,-"'0&-1%##' /-&'()%'R%<,1.&%'9.H,"4#'O&-4&.2#>'9-1,.3'9%1+&,(:'$,33'#%"<',"/-&2.(,-"'/&-2'(),#'/-&2'(-':-+&' #(.(%'+"3%##':-+'(%33'+#'"-('(-5'!"#:%&#C8-,#,%#.),#4)26#"(%0#,4)#<)=+78()#/8;+-.*#G(%.(80*A#=%# -%,#7%062),)#,4+*#f&)*,+%-F#b&*,#*+.-#8-=#=8,)#,4)# ,+%-#8-=#:%&(#*,8,)#C+22#7%-,87,#:%&F# # A/':-+'.&%'-%,',"(%&%#(%<',"'=3,"4'/-&'()%'R%<,1.&%'9.H,"4#'O&-4&.2#>'03.1%'."' ',"'()%';-P';%3-$5 M%A#=%#-%,#*)-=#,4)#+-"%(08,+%-#,%#,4)#*,8,)F!"#$%&&'()*+*,(-./(&0(12&3%4)+(+**56%@AB8%F

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