Form SSA-1026-REDE SSA Review of Your Eligibility for Extra Help

Statement for Continuing Eligibility
for Extra Help with Medicare
Prescription Drug Plan Costs

Please go to the next page
Form

SSA-1026-OCR-SM-REDE (08-2021) Recycle prior editions

Instructions for Completing the Statement
for Continuing Eligibility for Extra Help
with Medicare Prescription Drug Plan Costs
If You Are Assisting Someone Else With This Form

Answer the questions as if that person were completing the form. You must know that person’s
Social Security number, Medicare number, and financial information.
Also, complete Section B on page 6.

How To Complete This Form

• Refer to the Resources and Income Summary on the back of the enclosed letter
when completing this form;
• Use BLACK INK only;
• Keep your numbers, Xs and letters inside the boxes; use only CAPITAL letters;
• Do not add any handwritten comments on the form;
• Do not use dollar signs when entering money amounts. The dollar sign is
preprinted; and
• Cents can be rounded to the nearest whole dollar.
EXAMPLE

EXAMPLE

Put an X in the box. DO NOT fill
in or use check marks in boxes.

Use capital
letters when
entering answers

A B C D

X
CO R R EC T

I N CO R R EC T

Completing Your Form

Please use the enclosed pre-addressed stamped envelope to return your completed and
signed form to:
Social Security Administration
Wilkes-Barre Direct Operations
Center P.O. Box 1080
Wilkes-Barre, PA 18767
The Resources and Income Summary sheet on the back of the enclosed letter will assist you
in completing this form. Do not include the Resources and Income Summary sheet or any
attachments when you return the form in the enclosed postage-paid envelope. If we need
more information, such as statements from financial institutions, we will contact you.

If You Have Questions Or Need Help Completing This Form

You can call us toll-free at 1-800-772-1213, or if you are deaf or hard of hearing, you may
call our TTY number, 1-800-325-0778.
Form

SSA-1026-OCR-SM-REDE (08-2021)

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Form Approved
OMB No. 0960-0723

Statement for Continuing Eligibility for Extra Help
with Medicare Prescription Drug Plan Costs
THIS DOES NOT ENROLL YOU IN A
MEDICARE PRESCRIPTION DRUG PLAN.

FOR OFFICIAL USE ONLY
State
Code:

WBDOC
Exception:

1. Name (Print each letter in a separate box.)
FIRST NAME

MI
SUFFIX (Jr., Sr., etc.)

LAST NAME
SOCIAL SECURITY NUMBER

DATE OF BIRTH
(MM - DD - YYYY)
EXAMPLE
For January- September put a zero (0) in
the first box. May 20, 1935 should read:

MEDICARE NUMBER
(This number is printed on your Medicare card)

0 5 2 0 1 93 5
MM DD Y Y Y Y

2. Spouse’s Name (If you are married AND living together, print your spouse's name as it appears
on your spouse's Social Security card. If you are NOT currently married, do NOT live with
your spouse or if you ARE widowed, skip to Question 3.)
FIRST NAME

MI
SUFFIX (Jr., Sr., etc.)

LAST NAME
SPOUSE’S SOCIAL SECURITY NUMBER

SPOUSE’S DATE OF BIRTH
(MM - DD - YYYY)

SPOUSE’S MEDICARE NUMBER
3. If your marital status has not changed or you already reported the change to us, go to question 4.
If your marital status has changed and you did not report it to us, what is your current marital status?
Married (living together)
Divorced/Widowed/Separated/Annulled
Form

SSA-1026-OCR-SM-REDE (08-2021)

Date of change in marital status:
Page 2

4. If all of the information on the Resources and Income Summary is correct, place an
and go to question 11 on page 5, sign and return this form.

in the box

If any of the information on the Resources and Income Summary is incorrect, continue to
question 5.
5. We need to know about resources that you, your spouse (if married and living together) or both
of you have.
Instructions: Please look at the information we have about your resources on the
Resources and Income Summary on the back of the enclosed letter.
If the information has not changed, place an in the box and go to question 6.

If the information has changed, fill in the new amount in the boxes below.
Type of Resource

The Correct Amount Is

Bank accounts (checking, savings
and certificates of deposit)
Stocks, bonds, savings bonds, mutual
funds, Individual Retirement Accounts
or other similar investments
Cash

Value of real estate other than your home

6. Will some money from the sources listed in question 5 be used to pay for funeral or burial expenses?
Instructions: If YES, skip to question 7.
If NO, place an in the NO box, then go to question 7.
Do NOT place an in the spouse NO box if you did not provide spouse information in Question 2.

Form

YOU:

NO

SPOUSE:

NO

SSA-1026-OCR-SM-REDE (08-2021)

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7. 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?
Instructions: Please look at the information we have about your household size on the
Resources and Income Summary on the back of the enclosed letter. If the information has not
changed, place an in the box and go to question 8.
Please do not include yourself or your spouse in the number you enter. If your household
consists only of you or you and your spouse, place an in the ZERO box. Place an in only
one box.
ZERO

1

2

3

4

5

6

7

8

9 or more

8. We need to know about income not from work that you, your spouse (if married and living
together) or both of you have from any of the sources listed below.
Instructions: Please look at the information we have about your income not from work on the
Resources and Income Summary on the back of the enclosed letter.
If the information has not changed, place an

in the box and go to question 9.

If the information has changed, fill in the new amount in the boxes below. If you or your spouse
receive zero income from a source listed below, place an in the NONE box for that source.
The Correct Monthly Amount Is
Social Security benefits before deductions

NONE

Railroad Retirement benefits before deductions

NONE

Veteran’s benefits before deductions

NONE

Other pensions or annuities before deductions.
Do not include money you receive from
any item you included in question 5.

NONE

NONE

Form

SSA-1026-OCR-SM-REDE (08-2021)

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9. We need to know about annual earned income from work that you, your spouse (if married
and living together) or both of you have.
Instructions: Please look at the information we have about your earned income on the
Resources and Income Summary on the back of the enclosed letter.
If the information has not changed, place an in the box and go to question 10.
If the information has changed, fill in the new amount in the boxes below.
Type of Earned Income

The Correct Annual Amount Is
You

Wages before taxes and deductions

Spouse
You

Net earnings from self-employment

Spouse
You

Net loss from self-employment

Spouse

10. Do you, your spouse (if married and living together) or both have to pay for things that enable
you to work (also known as disability or blind work expenses)? We will count only a part of
your earnings toward the income limit if you work and receive Social Security benefits based on
a disability or blindness and you have work-related expenses for which you are not reimbursed.
Examples of such expenses are: the costs of medical treatment and drugs for AIDS, cancer,
depression or epilepsy; a wheelchair; personal attendant services; vehicle modifications, driver
assistance or other special work-related transportation needs; work-related assistive technology;
guide dog expenses; sensory and visual aids; and Braille translations.
Instructions: If NO, skip to question 11. If YES, place an

in the YES box then go to question 11.

Do NOT fill in the boxes next to SPOUSE if you did not put spouse information in Question 2.
YES
YES
YOU:
SPOUSE:
11. If you or your spouse (if married and living together) work and plan to stop working, enter
month and year. Otherwise sign the form on page 6 and return it to us.
Do NOT fill in the boxes next to SPOUSE if you did not put spouse information in Question 2.
2 0
E .X A M P L E
YOU:
For January – September,
M M
YYYY
put a zero (0) in the
first box. May 2021
should read:

Form

0 5

MM

2 0 2 1
YYYY

SSA-1026-OCR-SM-REDE (08-2021)

Page 5

SPOUSE:

2 0
M M

YYYY

Signatures
IMPORTANT INFORMATION - PLEASE READ CAREFULLY
I/We understand that the Social Security Administration (SSA) will check my/our statements and
compare its records with records from Federal, State, and local government agencies, including the
Internal Revenue Service (IRS) to make sure the determination is correct.
By submitting this form, I am/we are authorizing SSA to obtain and disclose information related
to my/our income, resources, and assets, foreign and domestic, consistent with applicable privacy
laws. This information may include, but is not limited to, information about my/our wages, account
balances, investments, benefits, and pensions.
I/We declare under penalty of perjury that I/we have examined all the information on this form and it
is true and correct to the best of my/our knowledge.
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
Date:

Your Signature:
Spouse’s Signature:

Phone Number:

Date:

Your Mailing Address:

Apt. #:

City:

State:

Zip Code:

If you changed your mailing address within the last three months, place an in the box:
If you would prefer that we contact someone else if we have additional questions, please provide the
person’s name and a daytime phone number.
Print First Name:

Print Last Name:

Phone Number:

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

in the box that describes who you are and provide your

Family Member

Attorney

Other Advocate

Friend

Agency

Social Worker

Print First Name:

Print Last Name:

Other
Specify:
Phone Number:

Address:

Apt. #:

City:
Form

State:
SSA-1026-OCR-SM-REDE (08-2021)

Page 6

Zip Code:

See Revised Privacy Act &
PRA Statements attached

Privacy Act / Paperwork Reduction Notice
Section 1860 D-14 of the Social Security Act authorizes the collection of information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may affect your eligibility for the Medicare Prescription Drug Plan (Part D) subsidy.
We will use the information to review and re-determine your eligibility for the 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 the Centers for Medicare and Medicaid Services, for the purpose of administering
Medicare Part D enrollment and premium collection and Medicare Advantage Part C
premium collections, as well as Medicare Part B income-related monthly adjustment
amounts.
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 Notice
(SORN) 60-0321, entitled Medicare Database File. Additional information and a full listing of
all our SORNs are available on our website at www.ssa.gov/privacy/sorn.html.
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 18 minutes to read the instructions, gather the
facts, and answer the questions. You may send comments on our time estimate above to:
SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our
time estimate to this address, not the completed form.
SEND THE COMPLETED FORM TO US AT THE ADDRESS SHOWN ON THE ENCLOSED
PRE-ADDRESSED, POSTAGE-PAID ENVELOPE:
Social Security Administration
Wilkes-Barre Direct Operations Center
P.O. Box 1080
Wilkes-Barre, PA 18767
Form

SSA-1026-OCR-SM-REDE (08-2021)

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SSA will insert the following revised Privacy Act & PRA Statements 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 affect your eligibility for the Medicare Prescription Drug Plan (Part D) subsidy.
We will use the information you provide to review and re-determine your eligibility for the
Medicare Part D subsidy. We may also share the information for the following purposes, called
routine uses:
•

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

•

To the Centers for Medicare and Medicaid Services, for the purpose of administering
Medicare Part D enrollment and premium collection and Medicare Advantage Part C
premium collections, as well as Medicare Part B income-related monthly adjustment
amounts.

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
(SORNs) 60-0310, entitled Medicare Savings Programs Information System, as published in the
Federal Register (FR) on March 31, 2004, at 69 FR 17019; and 60-0321, entitled Medicare
Database (MDB) File, as published in the FR on July 25, 2006, at 71 FR 42159. Additional
information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.

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
(OMB) control number. We estimate that it will take about 18 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments regarding this burden estimate
or any other aspect of this collection, including suggestions for reducing this burden to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.