Form SSA-1020 Application for Help with Medicare Prescription Drug Pla

Privacy
PrivacyAct
Act/ /Paperwork
PaperworkReduction
ReductionNotice
Notice

Social
SocialSecurity
SecurityAdministration
Administration
Important
ImportantInformation
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.
Paperwork
PaperworkReduction
ReductionAct
ActStatement
Statement- This
- Thisinformation
informationcollection
collectionmeets
meetsthetherequirements
requirementsofof4444U.S.C.
U.S.C.
§ §3507,
3507,asasamended
amendedbybysection
section2 2ofofthethePaperwork
PaperworkReduction
ReductionAct
Actofof1995.
1995.You
Youdodonot
notneed
needtotoanswer
answer
these
thesequestions
questionsunless
unlesswewedisplay
displaya valid
a validOffice
OfficeofofManagement
Managementand
andBudget
Budget(OMB)
(OMB)control
controlnumber.
number.
The
TheOMB
OMBcontrol
controlnumber
numberforforthis
thiscollection
collectionis is0960-0696.
0960-0696.We
Weestimate
estimatethat
thatit itwill
willtake
take3030minutes
minutestoto
read
readthetheinstructions,
instructions,gather
gatherthethefacts,
facts,and
andanswer
answerthethequestions.
questions.Send
Sendonly
onlycomments
commentsrelating
relatingtotoour
our
time
timeestimate
estimateabove
aboveto:to:SSA,
SSA,6401
6401Security
SecurityBlvd,
Blvd,Baltimore,
Baltimore,MD
MD21235-6401.
21235-6401.
SEND
SENDTHE
THECOMPLETED
COMPLETEDFORM
FORMTO
TOUS
USAT
ATTHE
THEADDRESS
ADDRESSSHOWN
SHOWNON
ONTHE
THEENCLOSED
ENCLOSED
PRE-ADDRESSED,
PRE-ADDRESSED,POSTAGE-PAID
POSTAGE-PAIDENVELOPE:
ENVELOPE:
Social
SocialSecurity
SecurityAdministration
Administration
Wilkes-Barre
Wilkes-BarreDirect
DirectOperations
OperationsCenter
Center
P.O.
P.O.Box
Box1020
1020
Wilkes-Barre,
Wilkes-Barre,PAPA18767-9910
18767-9910

You may be eligible to get Extra Help paying for your prescription drugs.
You may be eligible to get Extra Help paying for your prescription drugs.
The Medicare prescription drug program gives you a choice of prescription plans that offer various
offer various
Theof
Medicare
prescription
givestoyou
choice
of prescription
types
coverage.
In addition,drug
youprogram
may be able
getaExtra
Help
(a Medicareplans
Part Dthat
subsidy)
to pay
types
of
coverage.
In
addition,
you
may
be
able
to
get
Extra
Help
to
pay
for
the
monthly
premiums,
for monthly premiums, annual deductibles, and co-payments related to the
annual
deductibles,
and co-payments
related to the Medicare prescription drug program.
the
Medicare
Prescription
drug program.
Before
Beforewewecan
canhelp
helpyou,
you,you
youmust
mustfillfillout
outthis
thisapplication,
application,put
putit itininthe
theenclosed envelope
enclosed
it today. Or
may
complete at
an online application at
and
mail itenvelope
today, orand
you mail
may complete
an you
online
application
www.socialsecurity.gov. We will review your application
andreview
send you
letter to let and
you
www.ssa.gov/benefits/medicare/prescriptionhelp/
.We will
youra application
know
qualify
Toqualify
use thefor
Extra
Help,
you
enroll
in aHelp,
Medicare
send
youif ayou
letter
to letfor
youExtra
knowHelp.
if you
Extra
Help.
Tomust
use the
Extra
prescription
drug
you
must enroll
in aplan.
Medicare prescription drug plan.
IfIfyou
youneed
needhelp
helpcompleting
completingthe
theapplication,
application,call
callSocial
SocialSecurity
Securityatat1-800-772-1213
1-800-772-1213
(T(TTY
www.socialsecurity.gov.
1-800-325-0778).
Youcan
canfind
findmore
moreinformation
informationatatssa.gov.
TY 1-800-325-0778).
You
You
Youalso
alsomay
maybebeable
abletotoget
gethelp
helpfrom
fromyour
yourState
Statewith
withother
otherMedicare
Medicarecosts
costsunder
underthe
the
Medicare
MedicareSavings
SavingsPrograms.
Programs.ByBycompleting
completingthis
thisform,
form,you
youwill
willstart
startyour
yourapplication
application
process
processforfora aMedicare
MedicareSavings
SavingsProgram.
Program.We
Wewill
willsend
sendinformation
informationtotoyour
yourState
Statewho
whowill
will
contact
contactyou
youtotohelp
helpyou
youapply
applyforfora aMedicare
MedicareSavings
SavingsProgram
Programunless
unlessyou
youtell
tellususnot
nottotobyby
answering
answeringquestion
question1515ononthis
thisform.
form.
If Ifyou
youneed
needinformation
informationabout
aboutMedicare
MedicareSavings
SavingsPrograms,
Programs,Medicare
Medicareprescription
prescriptiondrug
drugplans
plans
ororhow
howtotoenroll
enrollinina plan,
a plan,call
call1-800-MEDICARE
1-800-MEDICARE(1-800-633-4227;
(1-800-633-4227;TTY
TTY1-877-486-2048)
1-877-486-2048)
ororvisit
visitwww.medicare.gov.
www.medicare.gov.You
Youalso
alsocan
canrequest
requestinformation
informationabout
abouthow
howtotocontact
contactyour
yourState
State
Health
HealthInsurance
InsuranceCounseling
Counselingand
and
Assistance
AssistanceProgram
Program(SHIP).
(SHIP).The
TheSHIP
SHIPoffers
offershelp
helpwith
withyour
your
Medicare
Medicarequestions.
questions.
Please
Pleasemail
mailyour
yourapplication
applicationtoday.
today.

Social Security Administration

Form
FormSSA-1020-OCR-SM
SSA-1020-OCR-SM(01-2021)
(01-2021)

Form
FormSSA-1020-OCR-SM
SSA-1020-OCR-SM(01-2021)
(01-2021)Recycle
Recycleprior
prioreditions
editions

Page7 7
Page

M011

Form
Form
SSA-1020-OCR-SM_03-2016
SSA-1020-OCR-SM_03-2016
Embedded_CS5adjusted.indd
Embedded_CS5adjusted.indd
1-2 1-2

5/12/16
5/12/16
4:304:30
PMPM

Form
FormApproved
Approved
OMB
OMBNo.
No.0960-0696
0960-0696

11.11.What
Whatdodoyou
youexpect
expectyour
yournet
netearnings
earningsfrom
fromself-employment
self-employmenttotobebethis
thiscalendar
calendaryear?
year?
Place
theNONE
NONEbox
boxif ifyou
youare
arenot
notself-employed
self-employedand
andgogototoquestion
question12.
12.
Placeanan ininthe
YOU:
YOU:

NONE
NONE

SPOUSE:
SPOUSE:

NONE
NONE

Place
Placeanan ininthe
thebox(es)
box(es)if ifyou
youororyour
your
spouse
spouseexpect
expecta anet
netloss.
loss.

Application
Applicationfor
forExtra
ExtraHelp
Helpwith
withMedicare
Medicare
Prescription
PrescriptionDrug
DrugPlan
PlanCosts
Costs

State
THIS
THISISISAN
ANAPPLICATION
APPLICATIONFOR
FOREXTRA
EXTRAHELP
HELPAND
ANDDOES
DOESNOT
NOT State
Code:
ENROLL
ENROLLYOU
YOUININAAMEDICARE
MEDICAREPRESCRIPTION
PRESCRIPTIONDRUG
DRUGPLAN.
PLAN. Code:

YOU:
YOU:

YES
YES

SPOUSE:
SPOUSE:

NO
NO

should read:

MM YYYY
MM YYYY

SPOUSE: M M
MM

Y2Y0Y Y
YYYY

IfIfyou
youare
areyounger
youngerthan
thanage
age65,
65,answer
answerquestion
question14.
14.IfIfyou
youare
aremarried
marriedand
and
living
livingwith
withyour
yourspouse
spouseand
andeither
eitherone
oneofofyou
youisisyounger
youngerthan
thanage
age65,
65,continue
continue
totoquestion
question14.
14.Otherwise,
Otherwise,skip
skiptotoquestion
question15.
15.
14.14.Do
Doyou
youororyour
yourspouse
spousehave
havetotopay
payforforthings
thingsthat
thatenable
enableyou
youtotowork?
work?We
Wewill
willcount
countonly
onlya apart
part
ofofyour
yourearnings
earningstoward
towardthe
theincome
incomelimit
limitif ifyou
youwork
workand
andreceive
receiveSocial
SocialSecurity
Securitybenefits
benefitsbased
based
onona adisability
disabilityororblindness
blindnessand
andyou
youhave
havework-related
work-relatedexpenses
expensesforforwhich
whichyou
youare
arenot
notreimbursed.
reimbursed.
Examples
Examplesofofsuch
suchexpenses
expensesare:
are:the
thecost
costofofmedical
medicaltreatment
treatmentand
anddrugs
drugsforforAIDS,
AIDS,cancer,
cancer,
depression
depressionororepilepsy;
epilepsy;a awheelchair;
wheelchair;personal
personalattendant
attendantservices;
services;vehicle
vehiclemodifications,
modifications,driver
driver
assistance
assistanceororother
otherspecial
specialwork-related
work-relatedtransportation
transportationneeds;
needs;work-related
work-relatedassistive
assistivetechnology;
technology;
guide
guidedog
dogexpenses;
expenses;sensory
sensoryand
andvisual
visualaids;
aids;and
andBraille
Brailletranslations.
translations.
Instructions; If NO, skip to question 15. If YES, place an in the YES box then go to question 15.
YOU:
YES
NO
SPOUSE:
YES
Do NOT
fill in the
boxes next
to SPOUSE if you did not put spouse
information
in QuestionNO
2.
YES your State
YES
YOU: about
SPOUSE:
15. Information
Medicare Savings Programs: You may be able
to get help from
Information
aboutcosts
Medicare
Savings
Programs:
may beTo
able
to get
help
from your
State
your Medicare
under the
Medicare
SavingsYou
Programs.
start
your
application
process
15.with
forwith
the your
Medicare
Savings
Programs,
Security
willPrograms.
send information
form to process
your
Medicare
costs
under theSocial
Medicare
Savings
To startfrom
your this
application
State
unless
you tellSavings
us not to.
If you want
toSecurity
get help will
fromsend
the information
Medicare Savings
Programs,
do
for the
Medicare
Programs,
Social
from this
form to your
not
complete
this
question.
Just
sign
and
date
the
application
and
your
State
will
contact
you.
State unless you tell us not to. If you want to get help from the Medicare Savings Programs, do
not complete this question. Just sign and date the application and your State will contact you.
If you are not interested in filing for the Medicare Savings Programs, place an in the box below.
If you are not interested in filing for the Medicare Savings Programs, place an in the box below.
No,
dodo
not
send
the
information
toto
the
State.
No,
not
send
the
information
the
Stat e.
Form
FormSSA-1020-OCR-SM
SSA-1020-OCR-SM(01-2021)
(01-2021)

Form
Form
SSA-1020-OCR-SM_03-2016
SSA-1020-OCR-SM_03-2016
Embedded_CS5adjusted.indd
Embedded_CS5adjusted.indd
5-6 5-6

Page
Page5 5

FIRSTNAME
NAME
FIRST

MI
MI

LAST
LASTNAME
NAME

If you
or your
spouse
stopped
working
2020
2021,
plan
to stop
working
in 2021
or 2022,
13.
or your
spouse,
stopped
working
in in
2020
or or
2021,
or or
plan
to stop
working
in 2021
or 2022,
13.If you
enter
month
year.
enter
thethe
month
andand
year.
Do NOT fill in the boxes next to SPOUSE if you did not put spouse
information in Question
2 0 2.
YOU:
EXAMPLE
YOU: M M
Y2Y0Y Y
EXAMPLE
For January – September,
MM
For January
– September,
place
a zero (0)
in the
2 Y0 Y Y Y
SPOUSE:

0 05 5 2 2 0 0 2 2 1 1

WBDOC
WBDOC
Exception:
Exception:

Applicant’sName:
Name:Print
Printname
nameasasit itappears
appearsononyour
yourSocial
SocialSecurity
Securitycard.
card.Use
Useone
onebox
boxforforeach
eachletter.
letter.
1.1. Applicant’s

12.
12.Have
Havethe
theamounts
amountsyou
youincluded
includedininquestions
questions1010oror1111decreased
decreasedininthe
thelast
lasttwo
twoyears?
years?

first
box.
May (0)
2021
place
a zero
in the
should
read:
first box.
May 2021

FOR
FOR
OFFICIAL
OFFICIAL
USE
USE
ONLY
ONLY

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

APPLICANT’S
APPLICANT’SSOCIAL
SOCIALSECURITY
SECURITYNUMBER
NUMBER APPLICANT’S
APPLICANT’SDATE
DATEOF
OFBIRTH
BIRTH
(MM-DD-YYYY)
(MM-DD-YYYY)
youare
aremarried
marriedand
andliving
livingwith
withyour
yourspouse,
spouse,please
pleaseprovide
providethe
thefollowing
followinginformation
informationasasit it
2.2. IfIfyou
appearsononyour
yourspouse’s
spouse’sSocial
SocialSecurity
Securitycard.
card.IfIfyou
youare
arenot
notcurrently
currentlymarried,
married,dodonot
notlive
livewith
with
appears
yourspouse
spouseororare
arewidowed,
widowed,skip
skiptotoquestion
question3 3and
anddodonot
notinclude
includeany
anyinformation
informationabout
aboutyour
your
your
spouseononthis
thisapplication.
application.
spouse

FIRST
FIRSTNAME
NAME

MI
MI

LASTNAME
NAME
LAST

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

SPOUSE’SSOCIAL
SOCIALSECURITY
SECURITYNUMBER
NUMBER
SPOUSE’S

SPOUSE’SDATE
DATEOF
OFBIRTH
BIRTH
SPOUSE’S
(MM-DD-YYYY)
(MM-DD-YYYY)

yourspouse
spousehas
hasMedicare,
Medicare,does
doesheheororshe
shealso
alsowish
wishtotoapply
applyforforthe
theExtra
ExtraHelp?
Help?
If Ifyour

YES
YES

NO
NO

youareare
married
marriedand
andlive
livewith
withyour
yourspouse,
spouse,dodoyou
youhave
havesavings,
savings,investments
investmentsororreal
realestate
estateworth
worth
3.3. If Ifyou
more
morethan
than$29,520?
$29,520?
If Ifyou
youarearenot
notmarried
marriedororyou
youdodonot
notlive
livewith
withyour
yourspouse,
spouse,is isthethevalue
valuemore
morethan
than
$14,790?
$14,790?
Do
DoNOT
NOTcount
countyour
yourhome,
home,vehicles,
vehicles,personal
personalpossessions,
possessions,life
lifeinsurance,
insurance,burial
burialplots,
plots,
irrevocable
irrevocableburial
burialcontracts
contractsororback
backpayments
paymentsfrom
fromSocial
SocialSecurity
SecurityororSSI.
SSI.
youplace
placeanan ininthe
theYES
YESbox,
box,you
youare
arenot
noteligible
eligiblefor
forthe
theExtra
ExtraHelp.
Help.But,
But,
YES IfIfyou
YES
your
yourState
Statemay
maybebeable
abletotohelp
helpyou
youwith
withyour
yourMedicare
Medicarecosts
coststhrough
throughtheir
theirMedicare
Medicare
Savings
SavingsPrograms.
Programs.ToTostart
startthe
theapplication
applicationprocess
processforforMedicare
MedicareSavings
SavingsPrograms,
Programs,
skip
skiptotopage
page6,6,sign
signthis
thisapplication
applicationand
andreturn
returnit ittotous.us.IfIfyou
youare
arenot
notinterested
interestedinin
Medicare
MedicareSavings
SavingsPrograms,
Programs,skip
skiptotoquestion
question1515ononpage
page5.5.
NO
NOoror
theNO
NOororNOT
NOTSURE
SUREbox,
box,complete
completethe
therest
restofofthis
this
IfIfyou
youplace
placeanan ininthe
NOT
NOTSURE
SURE application
applicationand
andreturn
returnit ittotous.us.
Form
FormSSA-1020-OCR-SM
SSA-1020-OCR-SM(01-2021)
(01-2021)

Page
Page2 2
M012

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5/12/16
4:304:30
PMPM

General
GeneralInstructions
Instructionsfor
forCompleting
Completingthe
the
Application
Applicationfor
forExtra
ExtraHelp
Helpwith
withMedicare
Medicare
Prescription
PrescriptionDrug
DrugPlan
PlanCosts
Costs
IfIfYou
YouAre
AreAssisting
AssistingSomeone
SomeoneElse
ElseWith
WithThis
ThisApplication
Application

Answer
Answerthe
thequestions
questionsasasif ifthat
thatperson
personwere
werecompleting
completingthe
theapplication.
application.You
Youmust
mustknow
knowthat
thatperson’s
person’s
Social
SocialSecurity
Securitynumber
numberand
andfinancial
financialinformation.
information.Also,
Also,complete
completeSection
SectionBBononpage
page6.6.
Do
Doyou
youhave
haveMedicare
Medicareand
andSupplemental
SupplementalSecurity
SecurityIncome
Income(SSI)
(SSI)ororMedicare
Medicareand
andMedicaid?
Medicaid?
IfIfthe
theanswer
answerisisYES,
YES,dodonot
notcomplete
completethis
thisapplication
applicationbecause
becauseyou
youautomatically
automaticallywill
willget
getthe
the
Extra
ExtraHelp.
Help.
Does
Doesyour
yourState
StateMedicaid
Medicaidprogram
programpay
payyour
yourMedicare
Medicarepremiums
premiumsbecause
becauseyou
youbelong
belongtotoa a
Medicare
MedicareSavings
SavingsProgram?
Program?
IfIfthe
theanswer
answerisisYES,
YES,contact
contactyour
yourState
StateMedicaid
Medicaidoffice
officefor
formore
moreinformation.
information.You
Youcould
couldget
getthe
the
Extra
ExtraHelp
Helpautomatically
automaticallyand
andmay
maynot
notneed
needtotocomplete
completethis
thisapplication.
application.

How
HowToToComplete
CompleteThis
ThisApplication
Application
•
•
•
•
•

•Use
UseBLACK
BLACKINK
INKonly;
only.
•Keep
Keepyour
yournumbers,
numbers,letters
lettersand
andXsXsinside
insidethe
theboxes;
boxes;use
useonly
onlyCAPITAL
CAPITALletters;
letters.
•Do
Donot
notadd
addany
anyhandwritten
handwrittencomments
commentsononthe
theapplication;
application.
Donot
notuse
usedollar
dollarsigns
signswhen
whenentering
enteringmoney
moneyamounts;
amounts.and
•Do
•Cents
Centscan
canbeberounded
roundedtotothe
thenearest
nearestwhole
wholedollar.
dollar.

Signatures
Signatures

IMPORTANT
IMPORTANTINFORMATION
INFORMATION- -PLEASE
PLEASEREAD
READCAREFULLY
CAREFULLY
I/We
I/We
understand
understand
that
that
thethe
Social
Social
Security
Security
Administration
Administration
(SSA)
(SSA)
will
will
check
check
my/our
my/our
statements
statements
and
and
compare
compare
itsits
records
records
with
with
records
records
from
from
Federal,
Federal,
State,
State,
and
and
local
local
government
government
agencies,
agencies,
including
including
thethe
Internal
Internal
Revenue
Revenue
Service
Service
(IRS)
(IRS)
toto
make
make
sure
sure
thethe
determination
determination
is is
correct.
correct.
ByBy
submitting
submitting
this
this
application,
application,
I am/we
I am/we
areare
authorizing
authorizing
SSA
SSA
toto
obtain
obtain
and
and
disclose
disclose
information
information
related
related
toto
my/our
my/our
income,
income,
resources,
resources,
and
and
assets,
assets,
foreign
foreign
and
and
domestic,
domestic,
consistent
consistent
with
with
applicable
applicable
privacy
privacy
laws.
laws.
This
This
information
information
may
may
include,
include,
butbut
is is
notnot
limited
limited
to,to,
information
information
about
about
my/our
my/our
wages,
wages,
account
account
balances,
balances,
investments,
investments,
benefits,
benefits,
and
and
pensions.
pensions.
Unless
Unless
I/we
I/we
answered
answered
“No”
“No”
toto
Question
Question
15,15,
I am/we
I am/we
areare
authorizing
authorizing
SSA
SSA
toto
disclose
disclose
toto
thethe
State
State
thethe
financial
financial
information
information
listed
listed
above
above
and
and
other
other
individually
individually
identifiable
identifiable
information
information
from
from
my/our
my/our
file,
file,
such
such
asas
my/our
my/our
name(s),
name(s),
date
date
ofof
birth,
birth,
gender
gender
and
and
Social
Social
Security
Security
number(s)
number(s)
toto
start
start
thethe
application
application
process
process
forfor
Medicare
Medicare
Savings
Savings
Programs.
Programs.
I/We
I/We
declare
declare
under
under
penalty
penalty
ofof
perjury
perjury
that
that
I/we
I/we
have
have
examined
examined
allall
thethe
information
information
onon
this
this
form
form
and
and
it it
is is
true
true
and
and
correct
correct
toto
thethe
best
best
ofof
my/our
my/our
knowledge.
knowledge.
Please
Please
complete
complete
Section
Section
A.A.
IfIf
you
you
cannot
cannot
sign,
sign,
a representative
a representative
may
may
sign
sign
forfor
you.
you.
IfIf
someone
someone
assisted
assisted
you,
you,
complete
complete
Section
Section
BB
asas
well.
well.

Section
SectionAA
Date:
Date:

Your
YourSignature:
Signature:
Spouse’s
Spouse’sSignature:
Signature:

Phone
PhoneNumber:
Number:

Date:
Date:

Your
YourMailing
MailingAddress:
Address:

Apt.
Apt.#:#:

City:
City:

EX
EA
XA
MM
PL
PE
LE
Place
DO
Placean
anX Xininthe
thebox.
box.
DONOT
NOTfill
fill
ininororuse
usecheck
checkmarks
marksininboxes.
boxes.

CORRECT
CORRECT

Use
Usecapital
capital
letters
letterswhen
when
AABBCCDD
entering
enteringanswers
answers

INCORRECT
INCORRECT

Completing
CompletingYour
YourApplication
Application

Youmay
maycomplete
completethe
theonline
onlineapplication
applicationatatwww.socialsecurity.gov
ssa.gov or use the enclosed
You
or use the enclosed
pre-addressed
pre-addressedstamped
stampedenvelope
envelopetotoreturn
returnyour
yourcompleted
completedand
andsigned
signedapplication
applicationto:to:
SocialSecurity
SecurityAdministration
Administration
Social
Wilkes-Barre
Wilkes-BarreDirect
DirectOperations
OperationsCenter
Center
P.O.
P.O.Box
Box1020
1020
Wilkes-Barre,
Wilkes-Barre,PA
PA18767-9910
18767-9910
Return
Returnthis
thisapplication
applicationpackage
packageininthe
theenclosed
enclosedenvelope.
envelope.Do
Donot
notinclude
includeanything
anythingelse
elseininthe
theenvelope.
envelope.
needmore
moreinformation,
information,wewewill
willcontact
contactyou.
you.
IfIfweweneed
NOTE:
NOTE:ToToapply,
apply,you
youmust
mustlive
liveininone
oneofofthe
the5050States
Statesororthe
theDistrict
DistrictofofColumbia.
Columbia.

IfIfyou
youwould
wouldprefer
preferthat
thatwewecontact
contactsomeone
someoneelse
elseif ifwewehave
haveadditional
additionalquestions,
questions,please
pleaseprovide
providethe
the
person’s
person’sname
nameand
anda adaytime
daytimephone
phonenumber.
number.
Print
PrintFirst
FirstName:
Name:

Print
PrintLast
LastName:
Name:

Phone
PhoneNumber:
Number:

Section
SectionBB
thebox
boxthat
thatdescribes
describesthat
thatperson
personand
andprovide
providethe
therest
restofofthe
the
IfIfsomeone
someoneassisted
assistedyou,
you,place
placeanan ininthe
information
informationrequested
requestedbelow.
below.
Family
FamilyMember
Member

Attorney
Attorney

Other
OtherAdvocate
Advocate

Friend
Friend

Agency
Agency

Social
SocialWorker
Worker

PrintFirst
FirstName:
Name:
Print

PrintLast
LastName:
Name:
Print

Other
Other
Specify:
Specify:
PhoneNumber:
Number:
Phone

Address:
Address:

IfIfYou
YouHave
HaveQuestions
QuestionsOr
OrNeed
NeedHelp
HelpCompleting
CompletingThis
ThisApplication
Application

You
Youcan
cancall
callusustoll-free
toll-freeatat1-800-772-1213,
1-800-772-1213,ororif ifyou
youare
aredeaf
deafororhard
hardofofhearing,
hearing,you
youmay
maycall
callour
our
TTY
TTYnumber,
number,1-800-325-0778.
1-800-325-0778.
Form
FormSSA-1020-OCR-SM
SSA-1020-OCR-SM(01-2021)
(01-2021)

Zip
ZipCode:
Code:

youchanged
changedyour
yourmailing
mailingaddress
addresswithin
withinthe
thelast
lastthree
threemonths,
months,place
placeanan here:
here:
If Ifyou

EX
EA
XA
MM
PL
PE
LE

XX

State:
State:

Apt.#:#:
Apt.

City:
City:

State:
State:

Form
FormSSA-1020-OCR-SM
SSA-1020-OCR-SM(01-2021)
(01-2021)

Page
Page1 1

ZipCode:
Code:
Zip

Page
Page6 6

Form
Form
SSA-1020-OCR-SM_03-2016
SSA-1020-OCR-SM_03-2016
Embedded_CS5adjusted.indd
Embedded_CS5adjusted.indd
3-4 3-4

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PMPM

IfIfyou
youplaced
placedanan ininthe
theNO
NOororNOT
NOTSURE
SUREbox
boxininquestion
question3,3,answer
answerallallofofthe
the
following
followingquestions.
questions.IfIfyou
youare
aremarried
marriedand
andliving
livingwith
withyour
yourspouse,
spouse,you
youmust
must
answer
answerallallofofthe
thequestions
questionsfor
forboth
bothofofyou.
you.
4.4. Enter
Enterbelow
belowmoney
moneyamounts
amountsofofallallbank
bankaccounts,
accounts,investments
investmentsororcash
cashthat
thatyou,
you,your
yourspouse,
spouse,if if
married
marriedand
andliving
livingtogether,
together,ororboth
bothofofyou
youown.
own.Also
Alsoinclude
includeitems
itemsthat
thateither
eitherofofyou
youown
ownwith
with
another
anotherperson.
person.Include
Includeonly
onlydollar
dollarfigures
figuresnot
notaccount
accountnumbers.
numbers.IfIfyou
youororyour
yourspouse
spousedodonot
notown
own
theNONE
NONEbox.
box.Do
DoNOT
NOTinclude
includea a
any
anyitem
itemlisted,
listed,alone
aloneororwith
withanother
anotherperson,
person,place
placeanan ininthe
back
backpayment
paymentfrom
fromSocial
SocialSecurity
SecurityororSSI
SSIreceived
receivedininthe
thelast
last1010months.
months.

NONE
NONE

Railroad
• RailroadRetirement
Retirementbenefits
benefits
before
beforedeductions
deductions

NONE
NONE

NONE
NONE

Veterans
• Veteransbenefits
benefitsbefore
beforedeductions
deductions

NONE
NONE

NONE
NONE

• Otherpensions
pensionsororannuities
annuitiesbefore
before
Other
deductions.Do
Donot
notinclude
includemoney
moneyyou
you
deductions.
receive
receivefrom
fromany
anyitem
itemyou
youincluded
includedinin
question
question4.4.

NONE
NONE

Other
income
not
listed
above,
• Other
income
not
listed
above,
including
alimony,
including
alimony,net
netrental
rentalincome,
income,
workerscompensation,
compensation,unemployment,
unemployment,
workers
private
privateororState
Statedisability
disabilitypayments,
payments,etc.
etc.
(Specify):
(Specify):_______________________
_______________________

NONE
NONE

NONE
NONE

• Combined
Combinedtotal
totalofofallallstocks,
stocks,bonds,
bonds,
savings
savingsbonds,
bonds,mutual
mutualfunds,
funds,
Individual
IndividualRetirement
RetirementAccounts
Accountsoror
other
othersimilar
similarinvestments
investments
• Any
Anyother
othercash
cashatathome
homeoror
anywhere
anywhereelse
else

5.5. Will
Willsome
somemoney
moneyfrom
fromthe
thesources
sourceslisted
listedininquestion
question4 4bebeused
usedtotopay
payforforfuneral
funeralororburial
burialexpenses?
expenses?
YES, skip
IfInstructions:
YES, skip toIfquestion
6. to question 6.
theNO
NObox,
box,then
thengo
gototoquestion
question6.6.
ininthe

Do NOT place an

in the spouse NO box if you did not provide spouse information in Question 2.
NO
NO
YOU:
SPOUSE:
SPOUSE:
YOU:
NO
NO

Otherthan
thanyour
yourhome
homeand
andthe
theproperty
propertyononwhich
whichit itisislocated,
located,dodoyou
youororyour
yourspouse,
spouse,if ifmarried
married
6.6. Other
andliving
livingtogether,
together,own
ownany
anyreal
realestate?
estate?Examples
Examplesofofother
otherreal
realestate
estateare
aresummer
summerhomes,
homes,rental
rental
and
propertiesororundeveloped
undevelopedland
landyou
youown
ownwhich
whichisisseparate
separatefrom
fromyour
yourhome.
home.
properties
YES
YES

NO
NO

7.7. For
Forthis
thisquestion,
question,a arelative
relativeisissomeone
someonerelated
relatedtotoyou
youbybyblood,
blood,adoption,
adoption,orormarriage
marriage(but
(butnot
not
including
includingyour
yourspouse).
spouse).How
Howmany
manyrelatives
relativeslive
livewith
withyou
youand
anddepend
dependononyou
youororyour
yourspouse
spouseforforatat
least
leastone-half
one-halfofoftheir
theirfinancial
financialsupport?
support?
Please
Pleasedodonot
notinclude
includeyourself
yourselfororyour
yourspouse
spouseininthe
thenumber
numberyou
youenter.
enter.If Ifyour
yourhousehold
householdconsists
consists
theZERO
ZERObox.
box.Place
Placeanan ininonly
onlyone
onebox.
box.
only
onlyofofyou
youororyou
youand
andyour
yourspouse,
spouse,place
placeanan ininthe
ZERO
ZERO

11

22

33

Form
FormSSA-1020-OCR-SM
SSA-1020-OCR-SM(01-2021)
(01-2021)

Form
Form
SSA-1020-OCR-SM_03-2016
SSA-1020-OCR-SM_03-2016
Embedded_CS5adjusted.indd
Embedded_CS5adjusted.indd
7-8 7-8

Monthly
MonthlyBenefit
Benefit
Social
• SocialSecurity
Securitybenefits
benefits
before
beforedeductions
deductions

• Combined
Combinedtotal
totalofofallallbank
bankaccounts
accounts
(checking,
(checking,savings
savingsand
andcertificates
certificates
ofofdeposit)
deposit)

NO,place
placean
an
IfIfNO,

8.8. IfIfyou
youororyour
yourspouse,
spouse,if ifmarried
marriedand
andliving
livingtogether,
together,receive
receiveincome
incomefrom
fromany
anyofofthe
thesources
sourceslisted
listed
below,
below,you
youmust
mustanswer
answerthe
thequestions
questionsforforboth
bothofofyou.
you.Please
Pleaseenter
enterthe
thetotal
totalamount
amountyou
youreceive
receive
each
eachmonth.
month.IfIfthe
theamount
amountchanges
changesfrom
frommonth
monthtotomonth
monthororyou
youdodonot
notreceive
receiveit itevery
everymonth,
month,
enter
enterthe
theaverage
averagemonthly
monthlyincome
incomefor
forthe
thepast
pastyear
yearfor
foreach
eachtype
typeininthe
theappropriate
appropriateboxes.
boxes.Do
Do
not
notlist
listwages
wagesand
andself-employment,
self-employment,interest
interestincome,
income,public
publicassistance,
assistance,medical
medicalreimbursements
reimbursementsoror
foster
fostercare
carepayments
paymentshere.
here.IfIfyou
youororyour
yourspouse
spousedodonot
notreceive
receiveincome
incomefrom
froma asource
sourcelisted
listedbelow,
below,
theNONE
NONEbox
boxforforthat
thatsource.
source.
place
placeanan ininthe

44

55

Page
Page3 3

66

77

88

9 9orormore
more

9.9. Have
Haveany
anyofofthe
theamounts
amountsyou
youincluded
includedininquestion
question8 8decreased
decreasedduring
duringthe
thelast
lasttwo
twoyears?
years?
YES
YES

NO
NO

IfIfyou
youhave
haveworked
workedininthe
thelast
lasttwo
twoyears,
years,you
youneed
needtotoanswer
answerquestions
questions10-14.
10-14.IfIf
you
youare
aremarried
marriedand
andliving
livingwith
withyour
yourspouse
spouseand
andeither
eitherone
oneofofyou
youhas
hasworked
worked
ininthe
thelast
lasttwo
twoyears,
years,you
youneed
needtotoanswer
answerquestions
questions10-14.
10-14.Otherwise,
Otherwise,skip
skiptoto
question
question15.
15.
10.
10.What
Whatdodoyou
youexpect
expecttotoearn
earnininwages
wagesbefore
beforetaxes
taxesand
anddeductions
deductionsthis
thiscalendar
calendaryear?
year?
YOU:
YOU:

NONE
NONE

SPOUSE:
SPOUSE:

NONE
NONE

Form
FormSSA-1020-OCR-SM
SSA-1020-OCR-SM(01-2021)
(01-2021)

Page
Page4 4

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