Current 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 spouse's 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 you provide.
Form SSA-1021 (07-2014)

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 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.
NO

Please return your completed appeal form, including the signature page, and any additional
information to:
Social Security Administration
Wilkes-Barre Data Operations Center
P.O. Box 1030
Wilkes-Barre, PA 18767-1030

Form SSA-1021 (07-2014)

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 someone assisted you,
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:

ZIP Code:
Apt. #:

State:

ZIP Code:

If you recently changed your address, put an X 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 someone assisted you, place an X in the box that describes that person and provide the rest of the
information requested below.
Family Member

Attorney

Advocate

Friend

Agency

Social Worker

Print First Name:

Print Last Name:

Other
Specify:

Phone Number:
( _____ ) ______ - ________

Address:

Apt. #:

City:
Form SSA-1021 (07-2014)

State:
Page 3

ZIP Code:

Privacy Act Statement
Collection and Use of Personal Information

Section 1860 D-14 of the Social Security Act, as amended, allows us to collect this information.
We will use the information you provide to determine your eligibility for help paying your share of
the cost of a Medicare Prescription Drug Plan.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
requested information could prevent an accurate and timely decision on your appeal.
We rarely use the information you supply for any purpose other than for making a determination
about your continuing entitlement to benefits. However, we may use the information for the
administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans’ Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
private concerns under contract to Social Security).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0321, entitled Medicare Database.
Additional information about this and other system of records notices and our programs are
available from our Internet website at www.socialsecurity.gov or at your local Social Security
office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
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, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments
relating to our time estimate to this address, not the completed form.

Form SSA-1021 (07-2014)

Page 4