Form i1020 Internet Application for Extra Help with Medicare Prescr

The Social Security Administration Emblem and Title now display at the top of every page.
The Extra Help With Medicare Prescription Drug Plan Costs banner has changed from a red and blue color scheme to a gray and blue color scheme.

Page Navigation

‘Next’ and ‘Previous’ buttons have replaced the ‘Previous’ and ‘Continue’ buttons.
The buttons have also moved from the right hand margin to the left hand margin.
The primary action, which is ‘Next’ in most cases, is presented first with the secondary action, ‘Previous’ following beside it.
The “Sign Out (Finish this Later)” button has changed to ‘Save & Exit’ and is located at the bottom of the screen

Progress Bar

The Progress Bar now contains numbered indicators, as opposed to plain unnumbered bullets.

Support Panel

Each data collection screen within the application now contains a Support Panel along the right-hand side. This Support Panel will include the #800 information as well as the agency’s hours of Operation.
The ‘Need Help?’ link is now contained within this Support Panel.

Text Size & Accessibility Help

The option to increase the text size is now available in the upper right hand corner of each screen.
An ‘Accessibility Help’ link is also now available in the upper right hand corner of each screen.

Progressive Disclosure

A new feature of the application will effectively condense the application when a question regarding income or wages is answered ‘No’. For instance, if the question “Do you expect to earn wages this calendar year?” is answered ‘No’, the user will not see the text and data collection field related to the amount of their expected wages.

Question and Answer Layout

The radio button options and associated text fields are now positioned below the question. Previously, these fields were located to the right of the question.

Phone Number Fields

Phone Number fields are now one input field as opposed to three smaller input fields.

Address Line Fields

All Address Line fields have been renamed as ‘Street Line’ fields. The number of available address fields has been reduced from 3 to 2, with the option to expand the number of fields to 4 if necessary. The ‘Apt No.’ field has been removed.

Name Fields

All Name Fields now have the ‘First’, ‘M.I.’, ‘Last’ and ‘Suffix’ field identifiers below the actual field. These indicators were previously under the field title (i.e. Spouse’s Name, Primary Applicant’s Name, etc)

SSN Fields

SSN fields did not previously accept dashes or hyphens. The ‘(Do NOT include dashes or hyphens.)’ reminder has been removed since the field now accepts these values.

Help Screens

All help screens now begin with ‘Help:’ with the appropriate topic following the colon. Each Help screen also contains a ‘Close’ box now as opposed to the text ‘Close this window to return to the application.’

Message Screens

On each Message screen that contains a ‘Close’ box, the text ‘Close this window to return to the application.’ was replaced with ‘Close’.

Welcome
1. User Interface

1. The Welcome Page now displays in a single column view as opposed to a two-column view.
2. The ‘What Do You Want To Do?’ box now contains only ‘Apply Now’ and ‘Return to An Existing Application’ options. The ‘Find Out If You Qualify’ option has been separated.
3. The Support Panel on the ‘Welcome’ page now contains the ‘Related Links’ section and the Privacy Act Statement hyperlink.
4. The Privacy Policy, Website Policy & Other Important Information and Site Map links formerly included in the Related Links section are now located at the bottom of the page.
5. The Welcome Page now allows the user to switch to Spanish. If selected, all the pages after this one will be presented in Spanish.
Welcome
1. User Interface

1. The Welcome Page now displays in a single column view as opposed to a two-column view.
2. The Support Panel on the ‘Welcome’ page now contains the ‘Related Links’ section and the Privacy Act Statement hyperlink.
3. The Privacy Policy, Website Policy & Other Important Information and Site Map links formerly included in the Related Links section are now located at the bottom of the page.
Should You Use This Application?
1. User Interface

1. Bullets moved between the question and sentence to make the question easier to understand.
2. Bullets removed from within questions for formatting purposes.
Welcome Back
1. User Interface

1. Added ‘(SSN)’ after ‘Social Security Number’
Save & Exit
1. User Interface

1. ‘i’ icon added to indicate important information. Background color set to light blue to draw attention to information. Section now titled ‘Save & Exit’ instead of ‘Sign Out’.
2. Added a ‘Print this Page’ link instead of directing user to the ‘Print Button’ at the top of their browser.
3. The ‘To Come Back To This Application’, ‘Last Date To Complete This Application’ and Important Information’ are now housed under a new section titled ‘Reentry Instructions’
You Are Not Eligible For The Extra Help
1. User Interface

Go Ahead
1. User Interface

Preparing To Find Out If You Qualify
1. User Interface

Preparing To Use This Application
1. User Interface

A. Area highlighted with background color.

(Apply Now)

About You and Your Spouse
1. User Interface

About You and Your Spouse - With
1. User Interface

1. The ‘Change This Answer’ button has been removed. Users can now change this answer, if necessary, by selecting the appropriate radio button. The ‘Note: Changing your answer…’ language was added to alert the user of the effects.
About You
1. User Interface

About the Person Completing
1. User Interface

Changes covered on Page 11.

About the Person Completing
1. User Interface

Changes covered on Page 11.

Reentry Number Issued Normal Process

User Interface

About You And Your Spouse's Living Situation - Married
1. User Interface

About Your Living Situation - Single
1. User Interface

Wages And Earnings - Married
1. User Interface

1. The ‘Change This Answer’ button has been removed. Users can now change this answer by selecting the appropriate radio button. The ‘Note: Changing your answer…’ language was added to alert the user of the effects.
2. Regardless of whether the spouse indicated work in 2010/2011, the application now asks the applicant and spouse wage and earnings question separately. Since the spouse did not indicate work on the above example, there is no field available for their wages and earnings. The current application asks ‘What do you or your spouse expect to earn in wages before taxes and deductions this calendar year?’
3. Similar to [B] above, the language referencing the spouse is removed from the question. Since the spouse did not indicate work on the above example, there is no field available for their wages and earnings. The question used to read ‘What do you or your spouse expect your net earnings from self-employment to be this calendar year?’
4. Similar to [B] and [C] above, the language referencing the spouse is removed from the question. Since the spouse did not indicate work on the above example, there is no field available for their wages and earnings. The question used to read ‘Have you or your spouse stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012?’
Wages And Earnings - Married
1. User Interface

1. The ‘Change This Answer’ button has been removed.
2. Here the question ‘What do you or your spouse expect to earn in wages before taxes and deductions this calendar year?’ is broken into two questions. The ‘What’ has been removed from the question as only an affirmative answer will reveal the ‘Amount of your expected wages’ language and input field.
3. Here the question ‘What do you or your spouse expect your net earnings from self-employment to be this calendar year?’ is broken into two questions. The ‘What’ has been removed from the question as only an affirmative answer will reveal the ‘Amount of your expected Net Earnings’ language and input field.
4. Here the question ‘Have you or your spouse stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012?’ is broken into two questions. An affirmative answer will reveal a follow-up question to capture the month and year. This is a new question and reads ‘When did you stop working in 2010 or 2011, or plan to stop working in 2011 or 2012?’
Wages And Earnings - Single (WITHOUT)
1. User Interface

1. The ‘Change This Answer’ button has been removed.
2. The ‘What’ has been removed from the question as only an affirmative answer will reveal the ‘Amount of your expected wages’ language and input field.
3. The ‘What’ has been removed from the question as only an affirmative answer will reveal the ‘Amount of your expected Net Earnings’ language and input field.
4. An affirmative answer to ‘Have you stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012?’ will reveal a follow-up question to capture the month and year. This is a new question and reads ‘When did you stop working in 2010 or 2011, or plan to stop working in 2011 or 2012?’
Wages And Earnings - Single (WITH)
1. User Interface

1. The ‘Change This Answer’ button has been removed.
2. The ‘What’ has been removed from the question as only an affirmative answer will reveal the ‘Amount of your expected wages’ language and input field.
3. The ‘What’ has been removed from the question as only an affirmative answer will reveal the ‘Amount of your expected Net Earnings’ language and input field.
4. An affirmative answer to ‘Have you stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012?’ will reveal a follow-up question to capture the month and year. This is a new question and reads ‘When did you stop working in 2010 or 2011, or plan to stop working in 2011 or 2012?’
Income Other Than Wages And Earnings - Married
1. User Interface

Similar to pages above, these questions are no longer phrased to include both the applicant and spouse together. Both the applicant and spouse must answer individual questions regarding SSA, RRB, VA and other pension and annuity questions. If the answer is ‘yes’, a follow-up question will be revealed to collect the amount.

Income Other Than Wages And Earnings - Single
1. User Interface

Resources - Married
1. User Interface

1. The first three questions were originally under an umbrella statement:
‘Do you or your spouse have any of the following resources? If Yes, enter the combined total for those items.

Combined total of all bank accounts (checking, savings and certificates of deposit)

Combined total of all stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or other similar investments

Any other Cash at home or anywhere else’

These questions were separated to improve clarity.
Resources - Single
1. User Interface

1. The first three questions were originally under an umbrella statement:
1. ‘Do you or your spouse have any of the following resources? If Yes, enter the combined total for those items.
2. Combined total of all bank accounts (checking, savings and certificates of deposit)
3. Combined total of all stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or other similar investments
4. Any other Cash at home or anywhere else’
5. These questions were separated to improve clarity.
Tool: Add Up Your Accounts
1. User Interface

Tool: Add Up Your Investments
1. User Interface

Tool: Add Up Your Other Pensions And Annuities
1. User Interface

Tool: Add Up Your Types Of Income
1. User Interface

(Find Out if You Qualify)
Find Out If You And Your Spouse Qualify (Married) Part 1 (WITHOUT)
1. User Interface

Find Out If You And Your Spouse Qualify (Married) Part 1 (WITH)
1. User Interface

The ‘Change This Answer’ button has been removed. Users can now change this answer, if necessary, by selecting the appropriate radio button. The ‘Note: Changing your answer…’ language was added to alert the user of the effects.

Find Out If You Qualify (Single) Part 1
1. User Interface

Find Out If You Qualify (Married) Part 3 (WITH)
1. U
  ser Interface

1. The ‘Change This Answer’ button has been removed. Users can now change this answer, if necessary, by selecting the appropriate radio button.
2. These questions previously applied to both applicant and spouse. The questions have been separated so that each member of the couple has their own question/answer.
Find Out If You Qualify (Single) Part 3 (WITHOUT)
1. User Interface

1. The ‘Change This Answer’ button has been removed. Users can now change this answer, if necessary, by selecting the appropriate radio button.
2. This question has been re-worded. It previously read: ‘What do you expect your net earnings from self-employment to be this calendar year?’ The ‘Amount of your expected wages before taxes and deductions this calendar year:’ and text box are now only displayed with an affirmative answer.
Find Out if You Qualify (Single) Part 3 (WITH)
1. User Interface

1. The ‘Change This Answer’ button has been removed. Users can now change this answer, if necessary, by selecting the appropriate radio button.
2. This question has been re-worded. It previously read: ‘What do you expect your net earnings from self-employment to be this calendar year?’ The ‘Amount of your expected wages before taxes and deductions this calendar year:’ and text box are now only displayed with an affirmative answer.
Find Out If You Qualify (Married) Part 2
1. User Interface

Shape2

Find Out If You Qualify (Single) Part 2
1. User Interface

Shape3

The ‘Amount of…’ and associated text boxes are only present with an affirmative answer.

Find Out If You Qualify (You Should Apply)
1. User Interface

Find Out If You Qualify (You Probably Do Not Qualify)
1. User Interface

Review and Send
Review Your Information
1. User Interface

Review Your Information
1. User Interface

1. This alert is now highlighted using a shaded box and exclamation point icon.
Ready to Submit
1. User Interface

The ‘Important’ note has been moved from just above the check box to the very top of the page.
The attestation section is now titled ‘Terms of Agreement’
The language following the check box previously read “I, John Doe, read and agree with the above.”

Ready to Submit
1. User Interface

1. The ‘Important’ note has been moved from just above the check box to the very top of the page.
2. The attestation section is now titled ‘Terms of Agreement’. The language following the check box has changed from ‘I, John Doe, read and agree with the above.’ To ‘I, John Doe agree with the terms of agreement above.’
3. Third Party Form Completers no longer attest that the information is true and correct to the best of their knowledge. Applicant attestation statements and electronic ‘signatures’ are now included when a third party form completer is completing the application. Third Party Form Completers also no longer authorize the disclosure of information on the applicant’s behalf. Third Party Form Completers now declare that the applicant(s) have authorized them to complete an application on their behalf and that the information reflected in the application was provided to them by the applicant(s).
Ready to Submit
1. User Interface

1. The ‘Important’ note has been moved from just above the check box to the very top of the page.
2. The attestation section is now titled ‘Terms of Agreement’. The language following the check box has changed from ‘I, Jane Doe, read and agree with the above.’
Ready to Submit
1. User Interface

1. The ‘Important’ note has been moved from just above the check box to the very top of the page.
2. The attestation section is now titled ‘Terms of Agreement’. The language following the check box has changed from ‘I, John Doe, read and agree with the above.’
3. Third Party Form Completers no longer attest that the information is true and correct to the best of their knowledge. Applicant attestation statements and electronic ‘signatures’ are now included when a third party form completer is completing the application. Third Party Form Completers also no longer authorize the disclosure of information on the applicant’s behalf. Third Party Form Completers now declare that the applicant(s) have authorized them to complete an application on their behalf and that the information reflected in the application was provided to them by the applicant(s).
Ready to Submit
1. User Interface

1. The ‘Important’ note has been moved from just above the check box to the very top of the page.
2. The attestation section is now titled ‘Terms of Agreement’. The language following the check box has changed from ‘I, John Doe, read and agree with the above.’ to ‘I, John Doe, agree with the terms of agreement above.’
Ready to Submit
1. User Interface

1. The ‘Important’ note has been moved from just above the check box to the very top of the page.
2. The attestation section is now titled ‘Terms of Agreement’. The language following the check box has changed from ‘I, John Doe, read and agree with the above.’
3. Third Party Form Completers no longer attest that the information is true and correct to the best of their knowledge. Applicant attestation statements and electronic ‘signatures’ are now included when a third party form completer is completing the application. Third Party Form Completers also no longer authorize the disclosure of information on the applicant’s behalf. Third Party Form Completers now declare that the applicant(s) have authorized them to complete an application on their behalf and that the information reflected in the application was provided to them by the applicant(s).
Successful Submission - Print Or Save Your Receipt
1. User Interface

Shape4

This section houses the same information, however, the layout has been changed to a single column view.

Unsuccessful Submission
1. User Interface

This field is highlighted with a shaded box.

Next Steps
1. User Interface

Missing Information (Fix Errors)
1. User Interface

Successful Submission - Print Or Save Yoour Receipt (print)
1. User Interface

This section houses the same information, however, the layout has been changed to a single column view.

Unsuccessful Submission
1. User Interface

1. This information is not highlighted using a shaded box.
Message Pages

“Please Confirm” message pages have been removed as they are no longer required with the navigational changes.

Authentication - Medicare Part D Database Not Eligible Or SSI Recipient

User Interface

Check The Social Security Number You Entered
1. User Interface

How The Online Application Works
1. User Interface

1. Added new language to accommodate new Spanish language option.
Privacy Act Statement
1. User Interface

Internet Security Policy
1. User Interface

Limit Number Of Restarts

User Interface

Limit Number Of Starts For A New Application
1. User Interface

Limit On The Number Of Tries To Start An Application
1. User Interface

Name Check Mismatch
1. User Interface

Not Eligible For The Prescription Drug Plan
1. User Interface

Off Hours Message
1. User Interface

Other Ways To Apply
1. User Interface

Paperwork Reduction Act Statement
1. User Interface

Print/Save/View Guide
1. User Interface

Processing Alert
1. User Interface

1. Changed text from “Continue” to “Next” due to navigational changes.
Sign-In Problem
1. User Interface

Special Instructions For Blind Users
1. User Interface

System Failure
1. User Interface

There Is A Pending Application For This Social Security Number
1. User Interface

Warning System Shutdown
1. User Interface

We Cannot Process Your Request
1. User Interface

What You Will Need
1. User Interface

You Do Not Live In One Of The 50 States Or DC
1. User Interface

You Have Already Sent Us An Application
1. User Interface

Your Session Has Expired
1. User Interface

Help Pages
Main Help Pages
1. User Interface

1. If you choose to Sign Out of changed to If you choose to Save & Exit
2. New Section Added to explain to the user that the application could be completed in English or Spanish. This section also explains to the user how to change languages if he/she has already started an application.
3. Removed language Close this window to return to the application. Replace with a left justified button that states Close.
Help: Are you assisting someone (other than your spouse who lives with you) with this application?
1. User Interface

Help: Did you (or your spouse, if married and living together) get an application in the mail from us?
1. User Interface

Help: Do you (or your spouse, if married and living together) have Medicare?
1. User Interface

Help: Are you (or your spouse, if married and living together) 64 years and 9 months old or older?
1. User Interface

Help: Have you (or your spouse, if married and living together) received:
1. User Interface

1. Bullets have been removed from the help question. The types of benefits are in list form, instead of in bullet form.
Help: In which state do you (or your spouse, if married and living together) live?
1. User Interface

Help: What is your marital status?
1. User Interface

Help: Do you have combined savings, investments, and real estate worth more than:
1. User Interface

Help: Have you worked in 2010 or 2011?
1. User Interface

1. Removed “(or your spouse, if married and living together)” after the first two words in the sentence “If you”.
2. Sentence changed from “If neither you nor your spouse worked in these years, we will not ask you about your wages and self-employment earnings when you complete the application for this help.” to “If you did not work in these years, we will not ask you about your wages and self-employment earnings when you complete the application for this help.”
Help: Has your spouse worked in 2010 or 2011?
1. User Interface

Help: Have you worked this calendar year?
1. User Interface

Help: Has your spouse worked this calendar year?
1. User Interface

Help: Are you UNDER age 65?
1. User Interface

Help: Is your spouse UNDER age 65?
1. User Interface

Help: Not counting your spouse, how many other relatives live in your household?
1. User Interface

Help: How many relatives live in your household and receive at least one-half of their financial support from you?
1. User Interface

Help: Do you have to pay for things related to a disability or blindness that enable you to work?
1. U
  ser Interface

1. Sentence changed from “Do you or your spouse have to pay for things related to a disability or blindness that enable you to work?” to “Do you have to pay for things related to a disability or blindness that enable you to work?”
Help: Does your spouse have to pay for things that enable him or her to work?
1. User Interface

New Help Screen. The help in the current application is one help page for many application questions. For the new application, there are individual help screens for each question. In the new application, we separated the applicant and spouse questions, so all the spousal questions are new and therefore all the spousal help pages are new.

Help: Do you expect to earn wages this calendar year?
1. User Interface

Changed Title from “What do you or your spouse expect to earn in wages before taxes and deductibles this calendar year?“ to “Help: Do you expect to earn wages this calendar year?”
First four words of the first sentence changed from “If you or your spouse” to “If you”.

Help: Does your spouse expect to earn wages this calendar year?
1. User Interface

Help: What do you expect your net earnings from self-employment to be this calendar year?
1. U
  ser Interface

1. Changed Title from “What do you or your spouse expect your net earnings from self-employment to be this calendar year?“ to “Help: What do you expect your net earnings from self-employment to be this calendar year?”
2. First four words of the first sentence changed from “If you or your spouse” to “If you”.
Help: What does your spouse expect the net earnings from self-employment to be this calendar year?
1. User Interface

Help: Have you stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012?
1. User Interface

Question changed from “Have you or your spouse stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012?” to “Help: Have you stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012?”
First four words of the first sentence changed from “If you or your spouse” to “If you”.

Help: Has you your spouse stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012?

User Interface

Help: Do you receive Social Security benefits?
1. U
  ser Interface

1. Question changed from “Do you or your spouse receive Social Security Benefits?” to “Help: Do you receive Social Security benefits?”
2. The first words of the first sentence have been changed from “If you or your spouse” to “If you”.
Help: Does your spouse receive Social Security benefits?
1. User Interface

Help: Do you receive Railroad Retirement benefits?
1. U
  ser Interface

1. Question changed from “Do you or your spouse receive Railroad Retirement Benefits?” to “Help: Do you receive Railroad Retirement Benefits?”
2. First words of first sentence changed from “If you or your spouse” to “If you”
Help: Does your spouse receive Railroad Retirement benefits?
1. User Interface

Help: Do you receive Veterans benefits?
1. User Interface

Question changed from “Do you or your spouse receive Veterans Benefits?” to “Help: Do you receive Veterans Benefits?”
First words of first sentence changed from “If you or your spouse” to “If you”

Help: Does your spouse receive Veterans benefits?
1. User Interface

Help: Do you receive income from other pensions or annuities?
1. U
  ser Interface

1. Question changed from “Do you or your spouse receive income from other pensions or annuities?” to “Help: Do you receive income from other pensions or annuities?”
2. First two sentences changed from “If you or your spouse currently receive income from a pension, enter the total amount received each month in this field. If you receive money from an insurance company (annuity) on a regular basis (monthly, yearly, etc.), enter that amount in this field as well.” to “If you currently receive income from a pension, select Yes and then enter the total amount received each month in the field provided. If you receive money from an insurance company (annuity) on a regular basis (monthly, yearly, etc.), enter that amount as well.”
3. Included the words Individual Retirement Accounts (IRAs).
Help: Does your spouse receive income from other pensions or annuities?
1. User Interface

Help: Do you receive other income not listed above, including alimony, net rental income, workers' compensation, etc.?
1. User Interface

Question changed from “Do you or your spouse receive other income not listed above, including alimony, net rental income, workers' compensation, private or state disability payments, etc.?” to “Help: Do you receive other income not listed above, including alimony, net rental income, workers' compensation, etc.?”
First words of first sentence changed from “Indicate whether you or your spouse” to “Indicate whether you”

Help: Does your spouse receive other income not listed above, including alimony, net rental income, workers' compensation, etc.?
1. User Interface

Help: Your Name
1. User Interface

Help: Your Social Security Number
1. User Interface

Help: What is your date of birth?
1. User Interface

Help: Spouse's Name
1. User Interface

Help: Spouse's Social Security Number
1. User Interface

Help: What is your spouse's date of birth?
1. User Interface

Help: Your Mailing Address
1. User Interface

Help: Your Phone Number
1. User Interface

Help: If your spouse has Medicare (or expects to have it in the next three months), does he or she also wish to apply?
1. User Interface

Help: Do you have combined savings, investments, and real estate worth more than $25,260?
1. User Interface

Help: OPTIONAL: (contact person)
1. User Interface

Help: Contact's Phone Number
1. User Interface

Help: Do you have combined savings, investments, and real estate worth more than $12,640?
1. User Interface

Help: Relationship to Applicant
1. User Interface

Help: Form Completer's Phone Number
1. User Interface

Help: Form Completer's Address
1. User Interface

Help: Primary Applicant's Name
1. User Interface

Help: Primary Applicant's Social Security Number
1. User Interface

Help: What is the primary applicant's date of birth?
1. User Interface

Help: Has the primary applicant worked in 2010 or 2011?
1. User Interface

Help: If the spouse has Medicare (or expects to have it in the next three months), does he or she also wish to apply?
1. User Interface

Help: Do the applicants have combined savings, investments, and real estate worth more than $25,260?
1. User Interface

Help: Spouse's Name
1. User Interface

Help: Spouse's Security Number
1. User Interface

Help: What is the spouse's date of birth?
1. User Interface

Help: Has the applicant's spouse worked in 2010 or 2011?
1. User Interface

Help: Mailing Address
1. User Interface

Help: Phone Number
1. User Interface

Help: Applicant's Name
1. User Interface

Help: Applicant's Social Security Number
1. User Interface

Help: What is the applicant's date of birth?
1. User Interface

Help: Has the applicant worked in 2010 or 2011?
1. User Interface

Help: Does the applicant have combined savings, investments, and real estate worth more than $12,640?
1. User Interface

Help: Have these wages or self-employment earnings decreased in the last two years?
1. User Interface

Help: Have these wages or self-employment earnings decreased in the last two years?
1. User Interface

Help: Has any of the income from these sources decreased in the last two years?
1. User Interface

Help: Has any of the income from these sources decreased in the last two years?
1. User Interface

Help: Do you or your spouse have bank accounts (checkings, savings and certificates of deposit)?
1. U
  ser Interface

1. Changed from “Do you or your spouse have any of the following resources? If Yes, enter the combined total for those items.
Combined total of all bank accounts (checking, savings and certificates of deposit)

Combined total of all stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or other similar investments

Any other cash at home or anywhere else” to “Help: Do you or your spouse have bank accounts (checking, savings and certificates of deposit)?”
Help: Do you or your spouse have stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or other similar investments?
1. U
  ser Interface

Changed from “Do you or your spouse have any of the following resources? If Yes, enter the combined total for those items.

Combined total of all bank accounts (checking, savings and certificates of deposit)

Combined total of all stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or other similar investments

Any other cash at home or anywhere else” to “Help: Do you or your spouse have stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or other similar investments?”

Help: Do you or your spouse have any other cash at home or anywhere else?
1. U
  ser Interface

1. Changed from “Do you or your spouse have any of the following resources? If Yes, enter the combined total for those items.
Combined total of all bank accounts (checking, savings and certificates of deposit)

Combined total of all stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or other similar investments

Any other cash at home or anywhere else” to “Help: Do you or your spouse have any other cash at home or anywhere else?”
Help: Do you have bank accounts (checkings, savings and certificates of deposit)?
1. U
  ser Interface

1. Changed from “Do you or your spouse have any of the following resources? If Yes, enter the combined total for those items.
Combined total of all bank accounts (checking, savings and certificates of deposit)

Combined total of all stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or other similar investments

Any other cash at home or anywhere else” to “Help: Do you have bank accounts (checking, savings and certificates of deposit)?”
Help: Do you have stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or other similar investments?
1. U
  ser Interface

1. Changed from “Do you or your spouse have any of the following resources? If Yes, enter the combined total for those items.
Combined total of all bank accounts (checking, savings and certificates of deposit)

Combined total of all stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or other similar investments

Any other cash at home or anywhere else” to “Help: Do you have stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or other similar investments?”
Help: Do you have any other cash at home or anywhere else?
1. U
  ser Interface

1. Changed from “Do you or your spouse have any of the following resources? If Yes, enter the combined total for those items.
Combined total of all bank accounts (checking, savings and certificates of deposit)

Combined total of all stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or other similar investments

Any other cash at home or anywhere else” to “Help: Do you have any other cash at home or anywhere else?”
Help: Will some money from any of the sources listed above be used to pay for your funeral or burial expenses?
1. User Interface

Help: Will some money from any of the sources listed above be used to pay for your spouse's funeral or burial expenses?
1. User Interface

Help: Other than your home and the property on which it is located, do you or your spouse own any real estate?
1. User Interface

Help: Other than your home and the property on which it is located, do you own any real estate?
1. User Interface

Help: Ready to submit
1. User Interface

“Submit Now” changed to “Sign Now”

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Fujitsu
File Modified	0000-00-00
File Created	2021-02-01

Form i1020 Internet Application for Extra Help with Medicare Prescr

Application for Help with Medicare Prescription Drug Plan Costs

i1020 (0960-0696) new screen shots

Internet Application for Help with Medicare Prescription Drug Plan Costs

OMB: 0960-0696

Sentence changed from “Do you or your spouse have to pay for things related to a disability or blindness that enable you to work?” to “Do you have to pay for things related to a disability or blindness that enable you to work?”

Changed Title from “What do you or your spouse expect your net earnings from self-employment to be this calendar year?“ to “Help: What do you expect your net earnings from self-employment to be this calendar year?”

Question changed from “Have you or your spouse stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012?” to “Help: Have you stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012?”

Changed from “Do you or your spouse have any of the following resources? If Yes, enter the combined total for those items.

Changed from “Do you or your spouse have any of the following resources? If Yes, enter the combined total for those items.

Changed from “Do you or your spouse have any of the following resources? If Yes, enter the combined total for those items.

Changed from “Do you or your spouse have any of the following resources? If Yes, enter the combined total for those items.

Changed from “Do you or your spouse have any of the following resources? If Yes, enter the combined total for those items.

Changed from “Do you or your spouse have any of the following resources? If Yes, enter the combined total for those items.