Ssa-9303

INFORMATION NEEDED FOR REVIEW OF THE APPLICATION FOR HELP WITH MEDICARE PRESCRIPTION DRUG PLAN COSTS

Please have the INFORMATION CHECKED BELOW on hand for the telephone review. Even if you do not have all of the information that is checked, I will help you get the information you do not have. We only need information about your spouse if you and your spouse were living together when you filed your application.

A. FAMILY SIZE AND HOUSEHOLD EXPENSES INFORMATION

□ Names, income amount and relationship of any relatives (by blood, marriage or adoption) living with you and your spouse for whom you and/or your spouse provide half of their support.

□ If you are living with anyone other than your spouse and/or minor children, have their name and amount they contribute towards the household expenses.

□ The monthly amount you paid for each one of the following items: food, mortgage/ rent, property insurance, property tax, heating fuel, electricity, gas, water, garbage removal and sewer for the time period __________________________________.

B. INCOME

□ Amount of wages that you or your spouse earned during the period _______________________________________.

□ The monthly amount of any pensions, or other benefit (other than Social Security benefits) you or your spouse receive.

C. RESOURCES

□ Balance in bank accounts during the period __________________________ for all accounts on which your name and/or your spouse’s name appear as individual or joint owner, or as a beneficiary.

□ Value of stocks, bonds, promissory notes, etc. owned by you or your spouse.

□ Location of property owned by you or your spouse other than the home you live in.

□ Amount in retirement savings accounts such as 401K, IRA, KEOGH, etc., owned by you or your spouse.

D. OTHER

□__________________________________________________________________

Checklist of Required Information

SSA-9304 (04/2007)