Form i1020 Internet Application for Extra Help with Medicare Prescr

0960-0696
i1020
Screen Shots
Table of Contents
Welcome ..................................................................................................................................................................... 10
User Interface ..................................................................................................................................................... 10
Welcome ................................................................................................................................................................ 11
User Interface ..................................................................................................................................................... 11
Should You Use This Application? .......................................................................................................................... 12
User Interface ...................................................................................................... Error! Bookmark not defined.
Welcome Back ........................................................................................................................................................ 13
User Interface ..................................................................................................................................................... 13
Save & Exit .............................................................................................................................................................. 14
User Interface .................................................................................................................................................... 14
You Are Not Eligible For The Extra Help ................................................................................................................ 15
User Interface ..................................................................................................................................................... 15
Go Ahead ................................................................................................................................................................ 16
User Interface ..................................................................................................................................................... 16
Preparing To Find Out If You Qualify ...................................................................................................................... 17
User Interface ..................................................................................................................................................... 17
Preparing To Use This Application .......................................................................................................................... 18
User Interface ..................................................................................................................................................... 18
(Apply Now) ............................................................................................................................................................ 19
About You and Your Spouse ................................................................................................................................... 19
User Interface ..................................................................................................................................................... 19
About You and Your Spouse - With......................................................................................................................... 20
User Interface ..................................................................................................................................................... 20
About You................................................................................................................................................................ 21
User Interface ..................................................................................................................................................... 21
About the Person Completing................................................................................................................................. 22
User Interface ..................................................................................................................................................... 23
About the Person Completing.................................................................................... Error! Bookmark not defined.
User Interface ...................................................................................................... Error! Bookmark not defined.
Reentry Number Issued Normal Process ................................................................................................................ 24
User Interface ..................................................................................................................................................... 24
About You And Your Spouse's Living Situation - Married........................................................................................ 25
User Interface ..................................................................................................................................................... 25
About Your Living Situation - Single ........................................................................................................................ 26
User Interface ..................................................................................................................................................... 26
Wages And Earnings - Married .............................................................................................................................. 27

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User Interface ..................................................................................................................................................... 27
Wages And Earnings - Married ............................................................................................................................... 28
User Interface ..................................................................................................................................................... 28
Wages And Earnings - Single (WITHOUT) ............................................................................................................. 29
User Interface .................................................................................................................................................... 29
Wages And Earnings - Single (WITH) ..................................................................................................................... 30
User Interface ..................................................................................................................................................... 30
Income Other Than Wages And Earnings - Married............................................................................................... 31
User Interface ..................................................................................................................................................... 31
Income Other Than Wages And Earnings - Single .................................................................................................. 32
User Interface .................................................................................................................................................... 32
Resources - Married ................................................................................................................................................ 33
User Interface ..................................................................................................................................................... 33
Resources - Single .................................................................................................................................................. 34
User Interface ..................................................................................................................................................... 34
Tool: Add Up Your Accounts ................................................................................................................................... 35
User Interface ..................................................................................................................................................... 35
Tool: Add Up Your Investments............................................................................................................................... 36
User Interface .................................................................................................................................................... 36
Tool: Add Up Your Other Pensions And Annuities .................................................................................................. 37
User Interface ..................................................................................................................................................... 37
Tool: Add Up Your Types Of Income....................................................................................................................... 38
User Interface .................................................................................................................................................... 38
(Find Out if You Qualify) .......................................................................................................................................... 39
Find Out If You And Your Spouse Qualify (Married) Part 1 (WITHOUT) ............................................................... 40
User Interface ..................................................................................................................................................... 40
Find Out If You And Your Spouse Qualify (Married) Part 1 (WITH)........................................................................ 43
User Interface ....................................................................................................... Error! Bookmark not defined.
Find Out If You Qualify (Single) Part 1 .................................................................................................................. 44
User Interface ..................................................................................................................................................... 44
Find Out If You Qualify (Married) Part 3 (WITH)...................................................................................................... 45
User Interface ..................................................................................................................................................... 45
Find Out If You Qualify (Single) Part 3 (WITHOUT) ................................................................................................ 46
User Interface ..................................................................................................................................................... 46
Find Out if You Qualify (Single) Part 3 (WITH) ....................................................................................................... 47
User Interface ..................................................................................................................................................... 47
Find Out If You Qualify (Married) Part 2 ................................................................... Error! Bookmark not defined.
User Interface ....................................................................................................... Error! Bookmark not defined.
Find Out If You Qualify (Single) Part 2 .................................................................... Error! Bookmark not defined.
User Interface ....................................................................................................... Error! Bookmark not defined.
Find Out If You Qualify (You Should Apply) ............................................................................................................ 48
User Interface ..................................................................................................................................................... 48

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Find Out If You Qualify (You Probably Do Not Qualify) ........................................................................................... 49
User Interface ..................................................................................................................................................... 49
Review and Send .................................................................................................................................................... 50
Review Your Information ......................................................................................................................................... 51
User Interface ..................................................................................................................................................... 51
Review Your Information ......................................................................................................................................... 52
User Interface ..................................................................................................................................................... 52
Ready to Submit ...................................................................................................................................................... 53
User Interface ..................................................................................................................................................... 53
Ready to Submit ...................................................................................................................................................... 54
User Interface ..................................................................................................................................................... 54
Ready to Submit ...................................................................................................................................................... 55
User Interface ..................................................................................................................................................... 55
Ready to Submit ...................................................................................................................................................... 56
User Interface ..................................................................................................................................................... 56
Ready to Submit ...................................................................................................................................................... 57
User Interface ..................................................................................................................................................... 57
Ready to Submit ...................................................................................................................................................... 58
User Interface ..................................................................................................................................................... 58
Successful Submission - Print Or Save Your Receipt ............................................................................................ 59
User Interface ..................................................................................................................................................... 59
Unsuccessful Submission ....................................................................................................................................... 60
User Interface ..................................................................................................................................................... 60
Next Steps ............................................................................................................................................................... 61
User Interface ..................................................................................................................................................... 61
Missing Information (Fix Errors) .............................................................................................................................. 62
User Interface ..................................................................................................................................................... 62
Successful Submission - Print Or Save Yoour Receipt (print) ................................................................................. 63
User Interface ..................................................................................................................................................... 63
Unsuccessful Submission ....................................................................................................................................... 64
User Interface ..................................................................................................................................................... 64
Message Pages...................................................................................................................................................... 65
Authentication - Medicare Part D Database Not Eligible Or SSI Recipient............................................................. 66
User Interface ..................................................................................................................................................... 66
Check The Social Security Number You Entered .................................................................................................... 67
User Interface .................................................................................................................................................... 67
How The Online Application Works ......................................................................................................................... 68
User Interface ..................................................................................................................................................... 68
Privacy Act Statement ............................................................................................................................................. 69
User Interface ..................................................................................................................................................... 69
Internet Security Policy............................................................................................................................................ 70
User Interface ..................................................................................................................................................... 70

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Limit Number Of Restarts ........................................................................................................................................ 71
User Interface ..................................................................................................................................................... 71
Limit Number Of Starts For A New Application........................................................................................................ 72
User Interface ..................................................................................................................................................... 72
Limit On The Number Of Tries To Start An Application ........................................................................................... 73
User Interface .................................................................................................................................................... 73
Name Check Mismatch .......................................................................................................................................... 74
User Interface .................................................................................................................................................... 74
Not Eligible For The Prescription Drug Plan ........................................................................................................... 75
User Interface .................................................................................................................................................... 75
Off Hours Message ................................................................................................................................................. 76
User Interface ..................................................................................................................................................... 76
Other Ways To Apply ............................................................................................................................................. 77
User Interface ..................................................................................................................................................... 77
Paperwork Reduction Act Statement....................................................................................................................... 78
User Interface ..................................................................................................................................................... 78
Print/Save/View Guide ............................................................................................................................................ 79
User Interface .................................................................................................................................................... 79
Processing Alert ..................................................................................................................................................... 80
User Interface .................................................................................................................................................... 80
Sign-In Problem...................................................................................................................................................... 81
User Interface .................................................................................................................................................... 81
Special Instructions For Blind Users........................................................................................................................ 82
User Interface ..................................................................................................................................................... 82
System Failure ........................................................................................................................................................ 83
User Interface ..................................................................................................................................................... 83
There Is A Pending Application For This Social Security Number .......................................................................... 84
User Interface .................................................................................................................................................... 84
Warning System Shutdown ..................................................................................................................................... 85
User Interface ..................................................................................................................................................... 85
We Cannot Process Your Request.......................................................................................................................... 86
User Interface ..................................................................................................................................................... 86
What You Will Need ................................................................................................................................................ 87
User Interface ..................................................................................................................................................... 87
You Do Not Live In One Of The 50 States Or DC .................................................................................................. 88
User Interface .................................................................................................................................................... 88
You Have Already Sent Us An Application .............................................................................................................. 89
User Interface ..................................................................................................................................................... 89
Your Session Has Expired....................................................................................................................................... 90
User Interface ..................................................................................................................................................... 90
Help Pages ............................................................................................................................................................. 91
Main Help Pages ..................................................................................................................................................... 92

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User Interface ..................................................................................................................................................... 92
Help: Are you assisting someone (other than your spouse who lives with you) with this application? .................... 93
User Interface ..................................................................................................................................................... 93
Help: Did you (or your spouse, if married and living together) get an application in the mail from us?.................... 94
User Interface ..................................................................................................................................................... 94
Help: Do you (or your spouse, if married and living together) have Medicare? ...................................................... 95
User Interface ..................................................................................................................................................... 95
Help: Are you (or your spouse, if married and living together) 64 years and 9 months old or older? ...................... 96
User Interface ..................................................................................................................................................... 96
Help: Have you (or your spouse, if married and living together) received: ............................................................. 97
User Interface .................................................................................................................................................... 97
Help: In which state do you (or your spouse, if married and living together) live? ................................................... 98
User Interface .................................................................................................................................................... 98
Help: What is your marital status? ........................................................................................................................... 99
User Interface ..................................................................................................................................................... 99
Help: Do you have combined savings, investments, and real estate worth more than: ......................................... 100
User Interface ................................................................................................................................................... 100
Help: Have you worked in 2011 or 2012? ............................................................................................................. 101
User Interface ................................................................................................................................................... 101
Help: Has your spouse worked in 2011 or 2012? .................................................................................................. 102
User Interface .................................................................................................................................................. 102
Help: Have you worked this calendar year? ......................................................................................................... 103
User Interface ................................................................................................................................................... 103
Help: Has your spouse worked this calendar year? .............................................................................................. 104
User Interface .................................................................................................................................................. 104
Help: Are you UNDER age 65? ............................................................................................................................ 105
User Interface ................................................................................................................................................... 105
Help: Is your spouse UNDER age 65? .................................................................................................................. 106
User Interface .................................................................................................................................................. 106
Help: Not counting your spouse, how many other relatives live in your household? ............................................. 107
User Interface ................................................................................................................................................... 107
Help: How many relatives live in your household and receive at least one-half of their financial support from you?
.............................................................................................................................................................................. 108
User Interface ................................................................................................................................................... 108
Help: Do you have to pay for things related to a disability or blindness that enable you to work? ......................... 109
User Interface .................................................................................................................................................. 109
Help: Does your spouse have to pay for things that enable him or her to work? ................................................... 110
User Interface .................................................................................................................................................. 110
Help: Do you expect to earn wages this calendar year? ....................................................................................... 111
User Interface .................................................................................................................................................. 111
Help: Does your spouse expect to earn wages this calendar year? ..................................................................... 112
User Interface ................................................................................................................................................... 112

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Help: What do you expect your net earnings from self-employment to be this calendar year? ............................. 113
User Interface ................................................................................................................................................... 113
Help: What does your spouse expect the net earnings from self-employment to be this calendar year? .............. 114
User Interface ................................................................................................................................................... 114
Help: Have you stopped working in 2011 or 2012, or plan to stop working in 2012 or 2013? ............................... 115
User Interface .................................................................................................................................................. 115
Help: Has you your spouse stopped working in 2011 or 2012, or plan to stop working in 2012 or 2013? ............. 116
User Interface .................................................................................................................................................. 116
Help: Do you receive Social Security benefits? ..................................................................................................... 117
User Interface ................................................................................................................................................... 117
Help: Does your spouse receive Social Security benefits? .................................................................................. 118
User Interface .................................................................................................................................................. 118
Help: Do you receive Railroad Retirement benefits? ............................................................................................. 119
.User Interface .................................................................................................................................................. 119
Help: Does your spouse receive Railroad Retirement benefits? ........................................................................... 120
User Interface .................................................................................................................................................. 120
Help: Do you receive Veterans benefits? .............................................................................................................. 121
User Interface .................................................................................................................................................. 121
Help: Does your spouse receive Veterans benefits? ............................................................................................. 122
User Interface .................................................................................................................................................. 122
Help: Do you receive income from other pensions or annuities?.......................................................................... 123
User Interface .................................................................................................................................................. 123
Help: Does your spouse receive income from other pensions or annuities? ........................................................ 124
User Interface .................................................................................................................................................. 124
Help: Do you receive other income not listed above, including alimony, net rental income, workers' compensation,
etc.? ...................................................................................................................................................................... 125
User Interface ................................................................................................................................................... 125
Help: Does your spouse receive other income not listed above, including alimony, net rental income, workers'
compensation, etc.? .............................................................................................................................................. 126
User Interface .................................................................................................................................................. 126
Help: Your Name .................................................................................................................................................. 127
User Interface .................................................................................................................................................. 127
Help: Your Social Security Number ...................................................................................................................... 128
User Interface .................................................................................................................................................. 128
Help: What is your date of birth? ........................................................................................................................... 129
User Interface .................................................................................................................................................. 129
Help: Spouse's Name ........................................................................................................................................... 130
User Interface ................................................................................................................................................... 130
Help: Spouse's Social Security Number ............................................................................................................... 131
User Interface .................................................................................................................................................. 131
Help: What is your spouse's date of birth? ............................................................................................................ 132
User Interface ................................................................................................................................................... 132

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Help: Your Mailing Address ................................................................................................................................... 133
User Interface ................................................................................................................................................... 133
Help: Your Phone Number .................................................................................................................................... 134
User Interface ................................................................................................................................................... 134
Help: If your spouse has Medicare (or expects to have it in the next three months), does he or she also wish to
apply? .................................................................................................................................................................... 135
User Interface .................................................................................................................................................. 135
Help: Do you have combined savings, investments, and real estate worth more than $25,260? .......................... 136
User Interface .................................................................................................................................................. 136
Help: OPTIONAL: (contact person) ....................................................................................................................... 137
User Interface ................................................................................................................................................... 137
Contact's Phone Number ..................................................................................................................................... 138
User Interface ................................................................................................................................................... 138
Help: Do you have combined savings, investments, and real estate worth more than $12,640? ......................... 139
User Interface ................................................................................................................................................... 139
Help: Relationship to Applicant............................................................................................................................. 140
User Interface .................................................................................................................................................. 140
Help: Form Completer's Phone Number................................................................................................................ 141
User Interface .................................................................................................................................................. 141
Help: Form Completer's Address ......................................................................................................................... 142
. User Interface ................................................................................................................................................. 142
Help: Primary Applicant's Name ............................................................................................................................ 143
. User Interface ................................................................................................................................................. 143
Help: Primary Applicant's Social Security Number ............................................................................................... 144
User Interface ................................................................................................................................................... 144
Help: What is the primary applicant's date of birth? ............................................................................................. 145
User Interface .................................................................................................................................................. 145
Help: Has the primary applicant worked in 2011 or 2012? ................................................................................... 146
User Interface ................................................................................................................................................... 146
Help: If the spouse has Medicare (or expects to have it in the next three months), does he or she also wish to
apply? .................................................................................................................................................................... 147
User Interface .................................................................................................................................................. 147
Help: Do the applicants have combined savings, investments, and real estate worth more than $25,260?......... 148
User Interface .................................................................................................................................................. 148
Help: Spouse's Name ........................................................................................................................................... 149
User Interface .................................................................................................................................................. 149
Help: Spouse's Security Number ........................................................................................................................... 150
User Interface ................................................................................................................................................... 150
Help: What is the spouse's date of birth? ............................................................................................................. 151
User Interface ................................................................................................................................................... 151
Help: Has the applicant's spouse worked in 2011 or 2012? ................................................................................. 152
User Interface .................................................................................................................................................. 152

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Help: Mailing Address ........................................................................................................................................... 153
User Interface ................................................................................................................................................... 153
Help: Phone Number ............................................................................................................................................ 154
User Interface ................................................................................................................................................... 154
Help: Applicant's Name ........................................................................................................................................ 155
User Interface ................................................................................................................................................... 155
Help: Applicant's Social Security Number ............................................................................................................ 156
User Interface .................................................................................................................................................. 156
Help: What is the applicant's date of birth? .......................................................................................................... 157
User Interface .................................................................................................................................................. 157
Help: Has the applicant worked in 2011 or 2012? ................................................................................................ 158
User Interface ................................................................................................................................................... 158
Help: Does the applicant have combined savings, investments, and real estate worth more than $12,640?....... 159
User Interface .................................................................................................................................................. 159
Help: Have these wages or self-employment earnings decreased in the last two years? .................................... 160
User Interface .................................................................................................................................................. 160
Help: Have these wages or self-employment earnings decreased in the last two years? ..................................... 161
User Interface ................................................................................................................................................... 161
Help: Has any of the income from these sources decreased in the last two years? .............................................. 162
User Interface ................................................................................................................................................... 162
Help: Has any of the income from these sources decreased in the last two years? .............................................. 163
User Interface .................................................................................................................................................. 163
Help: Do you or your spouse have bank accounts (checkings, savings and certificates of deposit)? ................... 164
User Interface ................................................................................................................................................... 164
Help: Do you or your spouse have stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or
other similar investments? ..................................................................................................................................... 165
User Interface ................................................................................................................................................... 165
1.158. Help: Do you or your spouse have any other cash at home or anywhere else? ......................................... 166
1.158.1. User Interface ..................................................................................................................................... 166
Help: Do you have bank accounts (checkings, savings and certificates of deposit)? ........................................... 167
User Interface .................................................................................................................................................. 167
Help: Do you have stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or other similar
investments? ......................................................................................................................................................... 168
User Interface .................................................................................................................................................. 168
Help: Do you have any other cash at home or anywhere else? ........................................................................... 169
User Interface .................................................................................................................................................. 169
Help: Will some money from any of the sources listed above be used to pay for your funeral or burial expenses?
.............................................................................................................................................................................. 170
User Interface .................................................................................................................................................. 170
Help: Will some money from any of the sources listed above be used to pay for your spouse's funeral or burial
expenses? ............................................................................................................................................................. 171
User Interface .................................................................................................................................................. 171

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Help: Other than your home and the property on which it is located, do you or your spouse own any real estate?
.............................................................................................................................................................................. 172
User Interface .................................................................................................................................................. 172
Help: Other than your home and the property on which it is located, do you own any real estate?....................... 173
. User Interface ..................................................................................................... Error! Bookmark not defined.
Help: Ready to submit .......................................................................................................................................... 174
. User Interface ..................................................................................................... Error! Bookmark not defined.

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Welcome
User Interface

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Welcome
User Interface

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Should You Use This Application?

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Welcome Back
User Interface

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Save & Exit

User Interface

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You Are Not Eligible For The Extra Help
User Interface

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Go Ahead
User Interface

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Preparing To Find Out If You Qualify
User Interface

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Preparing To Use This Application
User Interface

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(Apply Now)
About You and Your Spouse
User Interface

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About You and Your Spouse - With
User Interface

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About You
User Interface

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About the Person
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Completing

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Reentry Number Issued Normal Process
User Interface

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

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About Your Living Situation - Single
User Interface

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Wages And Earnings - Married
User Interface

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Wages And Earnings - Married
User Interface

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Wages And Earnings - Single (WITHOUT)
User Interface

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Wages And Earnings - Single (WITH)
User Interface

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Income Other Than Wages And Earnings – Married User Interface

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Income Other Than Wages And Earnings - Single
User Interface

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Resources - Married
User Interface

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Resources - Single
User Interface

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Tool: Add Up Your Accounts
User Interface

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Tool: Add Up Your Investments
User Interface

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Tool: Add Up Your Other Pensions And Annuities
User Interface

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Tool: Add Up Your Types Of Income
User Interface

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(Find Out if You Qualify)

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

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Find Out If You And Your Spouse Qualify

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

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Find Out If You Qualify (Married) Part 3 (WITH)
User Interface

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Find Out If You Qualify (Single) Part 3 (WITHOUT)
User Interface

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Find Out if You Qualify (Single) Part 3 (WITH)
User Interface

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

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

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Review and Send

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Review Your Information
User Interface

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Review Your Information
User Interface

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Ready to Submit
User Interface

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Ready to Submit
User Interface

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Ready to Submit
User Interface

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Ready to Submit
User Interface

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Ready to Submit
User Interface

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Ready to Submit
User Interface

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Successful Submission - Print Or Save Your Receipt
User Interface

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Unsuccessful Submission
User Interface

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Next Steps
User Interface

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Missing Information (Fix Errors)
User Interface

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Successful Submission - Print Or Save Your Receipt (print)
User Interface

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Unsuccessful Submission
User Interface

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Message Pages

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

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Authentication - Medicare Part D Database Not Eligible Or SSI Recipient
User Interface

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Check The Social Security Number You Entered
User Interface

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How The Online Application Works
User Interface

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Privacy Act Statement
User Interface

See revised
Privacy Act
Statement below
(last page of
document).

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Internet Security Policy
User Interface

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Limit Number Of Restarts
User Interface

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Limit Number Of Starts For A New Application
User Interface

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

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Name Check Mismatch
User Interface

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Not Eligible For The Prescription Drug Plan
User Interface

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Off Hours Message
User Interface

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Other Ways To Apply
User Interface

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Paperwork Reduction Act Statement
User Interface

Date to be updated
upon OMB
approval.

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Print/Save/View Guide
User Interface

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Processing Alert
User Interface

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Sign-In Problem
User Interface

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Special Instructions For Blind Users
User Interface

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System Failure
User Interface

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

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Warning System Shutdown
User Interface

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We Cannot Process Your Request
User Interface

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What You Will Need
User Interface

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

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You Have Already Sent Us An Application
User Interface

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Your Session Has Expired
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Help Pages

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Main Help Pages
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Help: Are you assisting someone (other than your spouse who lives with you) with this
application?
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Help: Did you (or your spouse, if married and living together) get an application in the mail from
us?
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Help: Do you (or your spouse, if married and living together) have Medicare?
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Help: Are you (or your spouse, if married and living together) 64 years and 9 months old or older?
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Help: Have you (or your spouse, if married and living together) received:
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Help: In which state do you (or your spouse, if married and living together) live?
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Help: What is your marital status?
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Help: Do you have combined savings, investments, and real estate worth more than:
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Help: Have you worked in 2011 or 2012?
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Help: Have you worked in 2011 or 2012?
When we determine whether you are eligible for help with prescription drug plan costs,
we consider the wages and self-employment net earnings that you (and your spouse, if
married and living together) receive.
If you worked in 2011 or 2012, we will ask you about your wages and self-employment
earnings when you complete the application for this help.
If you did not work in these years, we will not ask you about your wages and selfemployment earnings when you complete the application for this help.
If you worked in 2011 or 2012, select Yes.
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Help: Has your spouse worked in 2011 or 2012?
User Interface

Help: Has your spouse worked in 2011 or 2012?
When we determine eligibility for help with prescription drug plan costs, we
consider the wages and self-employment net earnings that your spouse
receives.
If your spouse worked in 2011 or 2012, we will ask about your spouse's
wages and self-employment earnings on the application for this help.
If your spouse has not worked in these years, we will not ask about your
spouse's wages and self-employment earnings when you complete this
application for this help.
If your spouse worked in 2011 or 2012, select Yes.
Close

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Help: Have you worked this calendar year?
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Help: Has your spouse worked this calendar year?
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Help: Are you UNDER age 65?
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Help: Is your spouse UNDER age 65?
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Help: Not counting your spouse, how many other relatives live in your household?
User Interface

Help: For this question, a relative is someone related to
you by blood, adoption, or marriage (but not including
your spouse). How many relatives live with you and
depend on you or your spouse for at least one-half of their
financial support? Please do not include yourself or your
spouse in the number you enter. If your household
consists only of you and your spouse, enter “0”.
Eligibility for the extra help is based on the amount of your income and that of your
spouse compared to the Federal Poverty Level for your household's size. Therefore, we
need to know how many other relatives are in your household for whom you or your
spouse provide at least one-half of their financial support. We count relatives related to
you by blood, marriage or adoption.

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

Help: For this question, a relative is someone related to
you by blood, adoption, or marriage. How many relatives
live with you and depend on you for at least one-half of
their financial support? Please do not include yourself in
the number you enter. If your household consists only of
you, enter “0”.
Eligibility for the extra help is based on the amount of your income compared to the
Federal Poverty Level for your household's size. Therefore, we need to know how many
relatives are in your household for whom you provide at least one-half of their financial
support. We count relatives related to you by blood, marriage or adoption.

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Help: Do you have to pay for things related to a disability or blindness that enable you to work?
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Help: Does your spouse have to pay for things that enable him or her to work?
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Help: Do you expect to earn wages this calendar year?
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Help: Does your spouse expect to earn wages this calendar year?
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Help: What do you expect your net earnings from self-employment to be this calendar year?
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Help: What does your spouse expect the net earnings from self-employment to be this calendar
year?
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Help: Have you stopped working in 2011 or 2012, or plan to stop working in 2012 or 2013?
User Interface

Help: Have you stopped working in 2011 or 2012, or plan
to stop working in 2012 or 2013?
If you have stopped working this year or last year, or plan to stop this year or next year,
select Yes and enter the month and year in the fields provided.
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Help: Has you your spouse stopped working in 2011 or 2012, or plan to stop working in 2012 or
2013?
User Interface

Help: Has your spouse stopped working in 2011 or 2012,
or plans to stop working in 2012 or 2013?
If your spouse has stopped working this year or last year, or plans to stop this year or
next year, select Yes and enter the month and year in the fields provided.
Close

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Help: Do you receive Social Security benefits?
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Help: Does your spouse receive Social Security benefits?
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Help: Do you receive Railroad Retirement benefits?
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Help: Does your spouse receive Railroad Retirement benefits?
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Help: Do you receive Veterans benefits?
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Help: Does your spouse receive Veterans benefits?
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Help: Do you receive income from other pensions or annuities?
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Help: Does your spouse receive income from other pensions or annuities?
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Help: Do you receive other income not listed above, including alimony, net rental income,
workers' compensation, etc.?
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Help: Does your spouse receive other income not listed above, including alimony, net rental
income, workers' compensation, etc.?
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Your Name
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Help: Your Social Security Number
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Help: What is your date of birth?
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Help: Spouse's Name
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Help: Spouse's Social Security Number
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Help: What is your spouse's date of birth?
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Help: Your Mailing Address
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Help: Your Phone Number
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Help: If your spouse has Medicare (or expects to have it in the next three months), does he or she
also wish to apply?
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Help: Do you have combined savings, investments, and real estate worth more than $25,260?
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Help: OPTIONAL: (contact person)
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Help: Contact's Phone Number
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Help: Do you have combined savings, investments, and real estate worth more than $12,640?
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Help: Relationship to Applicant
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Help: Form Completer's Phone Number
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Help: Form Completer's Address
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Help: Primary Applicant's Name
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Help: Primary Applicant's Social Security Number
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Help: What is the primary applicant's date of birth?
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Help: Has the primary applicant worked in 2010 or 2011?
User Interface

Help: Has the primary applicant worked in 2011 or 2012?
When we determine eligibility for help with prescription drug plan costs, we consider the
wages and self-employment net earnings of the person who is applying for this help. We
also consider the wages and net self-employment earnings of that person's spouse.
If the primary applicant worked in 2011 or 2012, we will ask about wages and selfemployment earnings on this application.
If the primary applicant did not work in these years, we will not ask about wages and
self-employment earnings on this application.
If the primary applicant worked in 2011 or 2012, select Yes.
Close

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Help: If the spouse has Medicare (or expects to have it in the next three months), does he or she
also wish to apply?
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Help: Do the applicants have combined savings, investments, and real estate worth more than
$25,260?
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Help: Spouse's Name
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Help: Spouse's Security Number
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Help: What is the spouse's date of birth?
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Help: Has the applicant's spouse worked in 2010 or 2011?
User Interface

Help: Has the applicant's spouse worked in 2011 or 2012?
When we determine eligibility for help with prescription drug plan costs, we consider the
wages and self-employment net earnings of the person who is applying for this help. We
also consider the wages and net self-employment earnings of that person.
If the primary applicant's spouse worked in 2011 or 2012, we will ask about wages and
self-employment earnings on this application.
If the primary applicant's spouse did not work in these years, we will not ask about
wages and self-employment earnings on this application.
Close

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Help: Mailing Address
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Help: Phone Number
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Help: Applicant's Name
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Help: Applicant's Social Security Number
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Help: What is the applicant's date of birth?
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Help: Has the applicant worked in 2010 or 2011?
User Interface

Help: Has the applicant's spouse worked in 2011 or 2012?
When we determine eligibility for help with prescription drug plan costs, we consider the
wages and self-employment net earnings of the person who is applying for this help. We
also consider the wages and net self-employment earnings of that person.
If the primary applicant's spouse worked in 2011 or 2012, we will ask about wages and
self-employment earnings on this application.
If the primary applicant's spouse did not work in these years, we will not ask about
wages and self-employment earnings on this application.

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Help: Does the applicant have combined savings, investments, and real estate worth more than
$12,640?
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Help: Have these wages or self-employment earnings decreased in the last two years?
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Help: Have these wages or self-employment earnings decreased in the last two years?
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Help: Has any of the income from these sources decreased in the last two years?
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Help: Has any of the income from these sources decreased in the last two years?
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Help: Do you or your spouse have bank accounts (checkings, savings and certificates of
deposit)?
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Help: Do you or your spouse have stocks, bonds, savings bonds, mutual funds, Individual
Retirement Accounts or other similar investments?
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Help: Do you or your spouse have any other cash at home or anywhere else?
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Help: Do you have bank accounts (checkings, savings and certificates of deposit)?
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Help: Do you have stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts
or other similar investments?
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Help: Do you have any other cash at home or anywhere else?
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Help: Will some money from any of the sources listed above be used to pay for your funeral or
burial expenses?
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A. Help: Will some money from any of the sources listed above be used to pay for your spouse's
funeral or burial expenses?
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A. Help: Other than your home and the property on which it is located, do you or your spouse own
any real estate?
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A. Help: Other than your home and the property on which it is located, do you own any real
estate?
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A. Help: Ready to submit
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SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information

Section 1860D-14 of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from making a decision on your eligibility for a Medicare Part D
subsidy.
We will use the information to obtain income and resource information to determine if you are
eligible for a Medicare Part D subsidy. We may also share your information for the following
purposes, called routine uses:
1. To applicants, claimants, prospective applicants or claimants (other than the data subjects
and their authorized representatives) to the extent necessary for the purpose of pursuing
Medicare Part D and Part D subsidy entitlement or appeal rights; and
2. To Federal, State, or local agencies (or agents on their behalf) for administering income
maintenance or health maintenance programs (including programs under the Social
Security Act).
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0090, entitled Master Beneficiary Record; and 60-0321, entitled Medicare Database
File. Additional information and a full listing of all our SORNs are available on our website at
https://www.ssa.gov/privacy/sorn.html.