Form SSA-44 Medicare Part B Income-Related Premium - Life Changing E

Form Approved

OMB No. XXXX-XXXX

S ocial Security Administration

Medicare Part B Income-Related Premium - Life-Changing Event

If you had a major life-changing event that has reduced your income, you may use this form to request a reduction in your Medicare Part B income-related premium. See page 6 for detailed information and line-by-line instructions. If you prefer to schedule an interview with your local Social Security office, call 1-800-772-1213 (TTY 1-800-325-0778).

Y our Name

Y __ __ __ - __ __ - __ __ __ __ our Social Security Number:

Background:

You may use this form if you received a notice that your monthly Medicare Part B premium includes an income-related monthly adjustment amount and you experienced a life-changing event that may reduce your income-related monthly adjustment amount. To decide this amount, we asked the Internal Revenue Service (IRS) about certain income from the Federal income tax return you filed for the 2005 tax year. If that was not available, we asked for your tax return information for 2004.

We used your adjusted gross income plus tax-exempt interest income which we call “modified adjusted gross income.” We took this information and used the table on page 2 to decide your income-related monthly adjustment amount.

The table at the top of page 2 of this form shows the income-related monthly adjustment amounts to your Medicare premium based on your tax filing status and income. If your modified adjusted gross income was lower than $80,000.01 (or lower than $160,000.01 if you filed your taxes with the filing status of married, filing jointly) in your most recent filed tax return, you do not have to pay an income-related monthly adjustment amount. If you do not have to pay an income-related monthly adjustment amount, you should not fill out this form even if you experienced a life-changing event.

If you filed your taxes as:	And your modified adjusted gross income was:	Your income-related amount is:
Single, Head of household, Qualifying widow(er) with dependent child, or Married filing separately (and you did not live with your spouse in tax year)*	$ 80,000.01 - $100,000.00 $100,000.01 - $150,000.00 $150,000.01 - $200,000.00 More than $200,000	$12.30 $30.90 $49.40 $67.90
Married, filing jointly	$160,000.01 - $200,000.00 $200,000.01 - $300,000.00 $300,000.01 - $400,000.00 More than $400,000	$12.30 $30.90 $49.40 $67.90
Married, filing separately (and you lived with your spouse during part of that tax year)*	$ 80,000.01 - $120,000.00 More than $120,000	$49.40 $67.90

* Let us know if your tax filing status for the tax year was Married, filing separately, but you lived apart from your spouse at all times during that tax year.

STEP 1: Type of Life-Changing Event: Check ONE Life-Changing Event and fill in the date that the event occurred (mm/dd/yyyy). If you had more than one life-changing event please call your local Social Security office at 1-800-772-1213 (TTY 1-800-325-0778).

	Marriage	_ _/_ _/_ _ _ _
	Divorce/Annulment	_ _/_ _/_ _ _ _
	Death of Your Spouse	_ _/_ _/_ _ _ _
	Work Stoppage	_ _/_ _/_ _ _ _
	Work Reduction	_ _/_ _/_ _ _ _
	Loss of Income Due to Property Loss	_ _/_ _/_ _ _ _
	Loss of Pension Income	_ _/_ _/_ _ _ _

STEP 2: Reduction in Income: Fill in the tax year in which your income was reduced by the life-changing event (see instructions on page 7), the amount of your adjusted gross income and tax-exempt interest income (if any), and your tax filing status.

T 20 __ __ ax Year:	A $ __ __ __ __ __ __ . __ __ djusted gross income:	Tax-Exempt Interest $ __ __ __ __ __ __ . __ __
Tax Filing Status for this Tax Year (choose ONE):  Single  Head of Household  Qualifying Widow(er) with Dependent Child  Married, Filing Jointly  Married, Filing Separately

STEP 3: Will your modified adjusted gross income be lower next year than the year in Step 2?

	No – skip to STEP 4
	Yes – complete the blocks below for next year

T 20 __ __ ax Year:	$ __ __ __ __ __ __ . __ __ Estimated Adjusted Gross Income:	Estimated Tax-Exempt Interest: $ __ __ __ __ __ __ . __ __
Expected Tax Filing Status for this Tax Year (choose ONE):  Single  Head of Household  Qualifying Widow(er) with Dependent Child  Married, Filing Jointly  Married, Filing Separately

STEP 4: Provide evidence of your modified adjusted gross income and your life-changing event

You can either:

1. Attach the required evidence and we will mail your original documents or certified copies back to you,

OR

2. Show your original documents or certified copies of evidence of your life-changing event and modified adjusted gross income to an SSA employee.

Note: You must sign on the next page, and attach all required evidence. Make sure that you provide your current address and a phone number so that we can contact you if we have any questions about your request.

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE SIGNING THIS FORM.

I declare under penalty of perjury that I have examined the information on this form and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison or may face other penalties, or both. I understand that the Social Security Administration (SSA) will check my statements with records from the Internal Revenue Service to make sure the determination is correct.

I understand that signing this form does not constitute a request for SSA to use more recent tax year information unless it is accompanied by the required evidence that I have had the life-changing event that I indicated on this form, and a copy of my Federal tax return or other evidence for the more recent tax year’s modified adjusted gross income.

Your Signature:	Phone Number:
Your Mailing Address:		Apt. #:
City:	State:	Zip Code:

THE PRIVACY ACT

We are required by section 1839(i) of the Social Security Act to ask you to give us the information on this form. This information is needed to determine if you qualify for a reduction in the income-related adjustment to your Medicare Part B premium. In order for us to determine if you qualify, we need to evaluate information that you provide to us about your modified adjusted gross income. Although the responses are voluntary, if you do not provide the requested information we will not be able to consider a reduction in your Medicare Part B premium.

Sometimes the law requires us to give out the facts on this form without your consent. We must release this information to another person or government agency if Federal law requires that we do so or to do the research and audits needed to administer or improve our efforts for the Medicare program. A detailed list of disclosures that we may make without your consent is available on SSA’s website at www.socialsecurity.gov

We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other agencies. We will compare the information you give us to your tax return records maintained by the Internal Revenue Service. The law allows us to do this even if you do not agree to it.

Explanation about these and other reasons why information you provide us may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office.

PAPERWORK REDUCTION ACT STATEMENT

This information collection meets the requirements of 44 U.S.C. §3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 90 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You may find your local office using your ZIP code from our web page, www.socialsecurity.gov on the Internet. The office is also listed under U.S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401.

Send only comments relating to our time estimate to this address, not the completed form.

General Instructions

You do not have to complete this form in order to ask that we use your information about your modified adjusted gross income for a more recent tax year. If you prefer, you may call 1-800-772-1213 and speak to a representative from 7 a.m. until 7 p.m. on business days to request an appointment at one of our field offices. If you are hearing-impaired, you may call our TTY number, 1-800-325-0778.

Identifying Information: Print your full name and your own Social Security Number as they appear on your Social Security Card. Your Social Security Number may be different from the number on your Medicare card.

STEP 1: You should choose only one life-changing event on the list. If you experienced more than one life-changing event, please call your local Social Security office at 1-800-772-1213 (TTY 1-800-325-0778).

Fill in the date that the life-changing event occurred. The life-changing event date must be in the same year or an earlier year than the tax year you ask us to use to decide your income-related premium adjustment. For example, if we used your 2005 tax information to determine your income-related monthly adjustment amount for 2007, you can request that we use your 2006 tax information instead if you experienced a reduction in your income in 2006 due to a life-changing event that occurred in 2006 or an earlier year.

Life-Changing Event	Use this category if…
Marriage	You entered into a legal marriage.
Divorce/Annulment	Your legal marriage ended, and you will not file a joint return with your spouse for the year.
Death of Your Spouse	Your spouse died.
Work Stoppage or Reduction	You or your spouse stopped working or reduced the hours that you work.
Loss of Income Due to Property Loss	You or your spouse experienced a reduction in your income due to a loss of income-producing property, that was not at your direction (e.g., not due to the sale or transfer of the property). This includes loss of income from real property in a Presidentially or Gubernatorially-declared disaster area, destruction of livestock or crops due to natural disaster or disease, or loss of income from property due to arson.
Loss of Pension Income	You or your spouse experienced a reduction in or loss of certain forms of pension income due to termination or reorganization of the pension plan or a scheduled cessation of benefits.

STEP 2: Supply information about the more recent year’s modified adjusted gross income. Note that this year must reflect a reduction in your income due to the life-changing event you listed in step 1. A change in your tax filing status due to the life-changing event might also reduce your income-related monthly adjustment amount. Your modified adjusted gross income is your adjusted gross income plus your tax-exempt interest income. We used your modified adjusted gross income and your tax filing status to set your income-related monthly adjustment amount.

Tax Year:

• Fill in both empty spaces in the box that says “20__ __”

• The year you choose must be more recent than the year of the tax return information we used. The letter that we sent you tells you what tax year we used.

  • Choose this year (the “premium year”) - if your modified adjusted gross income is lower this year than last year. For example, if you request that we adjust your income-related premium for 2007, use your estimate of your 2007 modified adjusted gross income if:

    • 1) your income was not reduced until 2007; or

    • 2) your income was reduced in 2006, but will be lower in 2007.

  • Choose last year (the year before the “premium year,” which is the year for which you want us to adjust your income-related premium) - if your modified adjusted gross income is not lower this year than last year. For example, if you request that we adjust your 2007 income-related premium, and your income was reduced in 2006 by a life-changing event AND will be no lower in 2007, use your tax information for 2006.

  • Exception: If we used IRS information about your modified adjusted gross income 3 years before the premium year, you may ask us to use information from 2 years before the premium year. For example, if we used your income tax return for 2004 to set your 2007 premium, you can ask us to use your 2005 information.

• If you have any questions about what year you should use, you should call SSA.

Adjusted Gross Income:

• Fill in your actual or estimated adjusted gross income for the year you wrote in the “tax year” box. On IRS form 1040, adjusted gross income is the amount on line 37. If you are providing an estimate, your estimate should be what you expect to enter on your tax return for that year.

Tax-exempt Interest:

• Fill in your actual or estimated tax-exempt interest income for the tax year you wrote in the “tax year” box. On IRS form 1040, tax-exempt interest income is reported on line 8b. If you are providing an estimate, your estimate should be what you expect to enter on your tax return for that year.

Filing Status:

• Check the box in front of your actual or expected tax filing status for the year you wrote in the “tax year” box.

STEP 3: Complete this step only if you expect that your modified adjusted gross income for next year will be even lower and will reduce your premium below what you told us in Step 2 using the table on page 2. We will record this information and use it to determine your income-related Medicare premium next year. If you do not complete Step 3, we will

use the information you provide in Step 2 next year to determine your income-related Medicare premium, unless one of the conditions described in “Important Facts” below occurs.

Tax Year:

• Fill in both empty spaces in the box that says “20__ __” with the year following the year you wrote in Step 2. For example, if you wrote “2007” in Step 2, then write “2008” in Step 3.

Adjusted Gross Income:

• Fill in your estimated adjusted gross income for the year you wrote in the “tax year” box. On IRS form 1040, adjusted gross income is the amount you expect to enter on line 37 when you file your tax return for that year.

Tax-exempt Interest:

• Fill in your estimated tax-exempt interest income for the tax year you wrote in the “tax year” box. On IRS form 1040, tax-exempt interest income is the amount you expect to report on line 8b.

Filing Status:

• Check the box in front of your expected tax filing status for the year you wrote in the “tax year” box.

STEP 4: Provide your required evidence of your modified adjusted gross income and your life-changing event.

• Modified adjusted gross income evidence

  • If you have filed your Federal income tax return for the year you wrote in Step 2, then you must provide us with your signed copy of your tax return or a transcript from IRS.

  • If you provided an estimate in Step 2, you must show us a signed copy of your tax return when you file your Federal income tax return for that year.

STEP 4 (con’t):

• Life-Changing Event Evidence

We must see original documents or certified copies of evidence that the life-changing event occurred. Required evidence is described below. In some cases, we may be able to accept another type of evidence, if you do not have a preferred document listed below. Ask a Social Security representative to explain what documentation is accepted.

Life-Changing Event	Evidence
Marriage	An original marriage certificate; or a certified copy of a public record of marriage.
Divorce/Annulment	A certified copy of the decree of divorce or annulment.
Death of Your Spouse	A certified copy of a death certificate, certified copy of the public record of death, or a certified copy of a coroner’s certificate.
Work Stoppage or Reduction	An original signed statement from your employer, copies of pay stubs, original or certified documents that show a transfer of your business. Note: If you do not have this type of proof, we will accept your signed statement, under penalty of perjury, on this form that you partially or fully stopped working or accepted a job with reduced compensation.
Loss of Income Due to Property Loss	An original or certified copy of an insurance company adjuster’s statement of loss or a letter from a State or Federal government about the uncompensated loss of income-producing property.
Loss of Pension Income	An original letter from the Pension Benefit Guaranty Corporation or your pension fund administrator.

Read the information above the signature line and sign the form. Fill in your phone number and current mailing address. It is very important that we have this information so that we can contact you if we have any questions about your request.

Important Facts

• When we use your estimated modified adjusted gross income information to make a decision about your Medicare Part B premium amount, we will later check with the IRS to verify your report.

• If you provide an estimate of your modified adjusted gross income, rather than a copy of your Federal tax return, we will ask you to provide a copy of your tax return when you file your taxes.

• If your estimate of your modified adjusted gross income changes, or you amend your tax return for that reason, you will need to contact us to update our records. If you do not contact us, we may have to make corrections later including retroactive assessments or refunds of premiums.

• We will use your estimate provided in Step 2 to make a decision about the amount of your Medicare Part B premium the following year until:

  • IRS sends us your tax return information for the year used in Step 2; or

  • You provide your copy of your filed Federal income tax return or amended Federal income tax return with a different amount; or

  • You provide an updated estimate.

• If we used information from IRS about a tax year when your filing status was Married filing separately, but you lived apart from your spouse at all times during that year, you should contact us at 1-800-772-1213 to explain that you lived apart from your spouse. Do not use this form to report this change.

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Form SSA-44