Old version of SSA-1021

Form Approved
OMB No. 0960-0695

Appeal of Determination for
Extra Help with Medicare
Prescription Drug Plan Costs

FOR OFFICIAL USE ONLY
Date received:
Office code:

Request filed late:

1. Applicant’s Name:

2. Social Security Number:

3. Medicare Number (if different from Social Security number):

4. Spouse’s Name (if spouse lives at same address as you):

5. Spouse’s Social Security Number (if spouse lives at same address as you):

6. Spouse’s Medicare Number (if different from Social Security number and spouse lives at same
address as you):

7. Please explain why you disagree with our decision:

8. Do you have additional information to support your appeal?
YES Send the additional information with this form to the address shown on the bottom
of page 2.
NO
9. Do you want a hearing? If you have a hearing, it will be by telephone.
YES You will receive a notice with the date and time of the hearing. Please complete
questions 10 through 13.
NO You will receive a decision based on the information available and any additional
information provided.
Form

SSA-1021 (10-2009)

Page 1

10. To give you time to prepare for the hearing, we must allow at least 20 days between the date
of your request and the date we schedule the hearing. Do you want a hearing sooner if
scheduling permits?
YES
NO
11. Do you need an interpreter?
YES (Specify language): __________________________________________________
NO
12. Are you hearing impaired?
YES
NO
13. Will you have other people at the hearing?
YES
NO
If YES, will you and the other people need to talk to us from more than one telephone number?
YES
NO
If YES, we call this a conference call. When we send you the notice scheduling the hearing, we
will give you a telephone number to use for this conference call and additional instructions for
setting up this call.
Please return your completed appeal form, including the signature page, and any additional
information to:
Social Security Administration
Wilkes-Barre Data
P.O. Box 1030
Wilkes-Barre, PA 18767-1030

Form

SSA-1021 (10-2009)

Page 2

Signatures
I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true to the best of my knowledge. I understand that making
a false statement is a crime punishable under Federal law. By submitting this appeal, I am authorizing the
Social Security Administration to obtain and disclose information related to my income, resources and
assets, foreign and domestic, consistent with applicable privacy laws. This information may include, but is
not limited to, information about my wages, account balances, investments, benefits, and pensions.
Please complete Section A. If you cannot sign, a representative may sign for you. If you are helping
someone to complete this form, complete Section B as well.

SECTION A

Your Signature:

Phone Number:

Your Home Street Address:

Apt. #:

City:

State:

Your Mailing Street Address (if different from home address):
City:

Apt. #:
State:

If you recently changed your address, put an

Zip Code:

Zip Code:

here:

If you would prefer that we contact someone else if we have additional questions, please provide the
person’s name and a daytime phone number.
Print First Name:

Print Last Name:

Phone Number:

SECTION B
If you are assisting someone else, place an
daytime phone number and address.

in the box that describes who you are and provide your

Family Member

Attorney

Advocate

Other
Specify: _______________

Friend

Agency

Social Worker

______________________

Print First Name:

Print Last Name:

Phone Number:

Address:

Apt. #:

City:
Form

State:
SSA-1021 (10-2009)

Page 3

Zip Code:

Privacy Act / Paperwork Reduction Notice
Section 1860 D-14 of the Social Security Act authorizes the collection of information
requested on this form. The information you provide will be used to enable the Social
Security Administration (SSA) to determine if you are eligible for help paying your
share of the cost of a Medicare Prescription Drug Plan. You do not have to give us
the information requested. However, if you do not provide the information, we will
be unable to make an accurate and timely decision on your appeal. We may provide
information collected on this form to another Federal, state, or local government agency
to assist us in determining your eligibility for the subsidy or if a Federal law requires
the release of information. We also may need to share the information with other SSA
programs if SSA needs to determine your eligibility in those programs.
We also may use the information you give us when we match records by computer.
Matching programs compare our records with those of other Federal, state, or local
government agencies. Many agencies may use matching programs to find or prove that
a person qualifies for benefits paid by the Federal Government. The law allows us to
do this even if you do not agree to it. Explanations 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
10 minutes to read the instructions, gather the facts, and answer the questions. You may
send comments on our time estimate above to: Social Security Administration, 1338
Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our
time estimate to this address, not the completed form.

Form

SSA-1021 (10-2009)

Page 4