Form Ssa 1020B PDF Details

Navigating the Medicare landscape can seem daunting, particularly when it comes to managing the costs associated with prescription drug plans. Enter form SSA-1020B, a crucial document for individuals seeking Extra Help with Medicare Prescription Drug Plan Costs. This application is a gateway for eligible applicants to potentially lower their expenses related to monthly premiums, annual deductibles, and copayments under the Medicare prescription drug program. Designed by the Social Security Administration, this form serves as the first step in determining whether an individual qualifies for Extra Help. Eligibility requires filling out and submitting this application, which can be completed and mailed in or done online at the official Social Security website. For those who automatically qualify for Extra Help because of their enrollment in Medicare and Supplemental Security Income (SSI) or Medicaid, completing this form may not be necessary. However, the instructions within the form also guide users through the process of applying for Medicare Savings Programs, offering a broader spectrum of assistance beyond just prescription costs. It’s important for applicants to provide accurate financial information and adhere to specific instructions such as using black ink and capital letters for clarity. Should there be complexities or questions during the application process, the form outlines resources including direct contact with the Social Security Administration and Medicare for comprehensive support. This form, therefore, stands as an essential document for those navigating the complexities of healthcare costs, aiming to make prescription drug coverage more accessible and affordable.

QuestionAnswer
Form NameForm Ssa 1020B
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namessocial security extra help application, secure ssa gov i1020 start, lis application form, social security form ssa 1020

Form Preview Example

Social Security Administration

Important Information

THIS COVER LETTER IS FOR INFORMATION ONLY. DO NOT

COMPLETE THE FOLLOWING PAGES. THIS IS NOT AN

APPLICATION.

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 types of coverage. In addition, you may be able to get Extra Help to pay for the monthly premiums, annual deductibles, and co-payments related to the Medicare prescription drug program.

But before we can help you, you must fill out this application, put it in the enclosed envelope and mail it today. Or you may complete an online application at www.socialsecurity.gov. We will review your application and send you a letter to let you know if you qualify for Extra Help. To use the Extra Help, you must enroll in a Medicare prescription drug plan.

If you need help completing the application, call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You can find more information at www.socialsecurity.gov.

You also may be able to get help from your State with other Medicare costs under the Medicare Savings Programs. By completing this form, you will start your application process for a Medicare Savings Program. We will send information to your State who will contact you to help you apply for a Medicare Savings Program unless you tell us not to by answering question 15 on this form.

If you need information about Medicare Savings Programs, Medicare prescription drug plans or how to enroll in a plan, call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048) or visit www.medicare.gov. You also can request information about how to contact your State Health Insurance Counseling and Assistance Program (SHIP). The SHIP offers help with your Medicare questions.

Please mail your application today.

Carolyn W. Colvin

Acting Commissioner

Form SSA-1020B-OCR-SM-INST (01-2014) Recycle prior editions

DO NOT COMPLETE THIS IS NOT AN APPLICATION.

General Instructions for Completing the Application for Extra Help with Medicare Prescription Drug Plan Costs

If You Are Assisting Someone Else With This Application

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

Do you have Medicare and Supplemental Security Income (SSI) or Medicare and Medicaid?

If the answer is YES, do not complete this application because you automatically will get the

Extra Help.

Does your State Medicaid program pay your Medicare premiums because you belong to a Medicare Savings Program?

If the answer is YES, contact your State Medicaid office for more information. You could get the

Extra Help automatically and may not need to complete this application.

How To Complete This Application

•Use BLACK INK only;

•Keep your numbers, letters and Xs inside the boxes; use only CAPITAL letters;

•Do not add any handwritten comments on the application;

•Do not use dollar signs when entering money amounts; and

•Cents can be rounded to the nearest whole dollar.

Completing Your Application

You may complete the online application at www.socialsecurity.gov or use the enclosed pre-addressed stamped envelope to return your completed and signed application to:

Social Security Administration

Wilkes-Barre Data Operations Center

P.O. Box 1020

Wilkes-Barre, PA 18767-9910

Return this application package in the enclosed envelope. Do not include anything else in the envelope. If we need more information, we will contact you.

NOTE: To apply, you must live in one of the 50 States or the District of Columbia.

If You Have Questions Or Need Help Completing This Application

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-1020B-OCR-SM-INST (01-2014) Page 1

DO NOT COMPLETE THIS IS NOT AN APPLICATION.

Form Approved

OMB No. 0960-0696

Application for Extra Help with Medicare Prescription Drug Plan Costs

THIS IS AN APPLICATION FOR EXTRA HELP AND DOES NOT ENROLL YOU IN A MEDICARE PRESCRIPTION DRUG PLAN.

FOR OFFICIAL USE ONLY

State

 

 

WBDOC

Code:

 

 

Exception:

 

 

1.Applicant’s Name: Print name as it appears on your Social Security card. Use one box for each letter.

FIRST NAME

 

 

 

 

 

 

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST NAME

 

 

 

 

 

 

 

SUFFIX (Jr., Sr., etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT’S DATE OF BIRTH

APPLICANT’S SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(MM-DD-YYYY)

2.If you are married and living with your spouse, please provide the following information as it appears on your spouse’s Social Security card. If you are not currently married, do not live with your spouse or are widowed, skip to question 3 and do not include any information about your spouse on this application.

FIRST NAME

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST NAME

 

 

 

 

SUFFIX (Jr., Sr., etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPOUSE’S SOCIAL SECURITY NUMBER

SPOUSE’S DATE OF BIRTH

 

(MM-DD-YYYY)

If your spouse has Medicare, does he or she also wish to apply for the Extra Help? YES

NO

3.If you are married and live with your spouse, do you have savings, investments or real estate worth more than $26,860? If you are not married or you do not live with your spouse, is the value more than $13,440? Do NOT count your home, vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.

YES

If you place an X in the YES box, you are not eligible for the Extra Help. But,

 

 

your State may be able to help you with your Medicare costs through their Medicare

Savings Programs. To start the application process for Medicare Savings Programs, skip to page 6, sign this application and return it to us. If you are not interested in Medicare Savings Programs, skip to question 15 on page 5.

NO or

If you place an in X the NO or NOT SURE box, complete the rest of this

NOT SURE

application and return it to us.

Form SSA-1020B-OCR-SM-INST (01-2014) Page 2

DO NOT COMPLETE THIS IS NOT AN APPLICATION.

If you placed an X in the NO or NOT SURE box in question 3, answer all of the following questions. If you are married and living with your spouse, you must answer all of the questions for both of you.

4.Enter below money amounts of all bank accounts, investments or cash that you, your spouse, if married and living together, or both of you own. Also include items that either of you own with another person. Include only dollar figures not account numbers. If you or your spouse do not own any item listed, alone or with another person, place an X in the NONE box. Do NOT include a back payment from Social Security or SSI received in the last 10 months.

•

Combined total of all bank accounts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(checking, savings and certificates

NONE

$

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

,

 

 

 

 

 

 

 

of deposit)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

•

Combined total of all stocks, bonds,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

savings bonds, mutual funds,

NONE

$

 

 

 

,

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual Retirement Accounts or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

other similar investments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

•

Any other cash at home or

NONE

$

 

 

 

,

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

anywhere else

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.Will some money from the sources listed in question 4 be used to pay for funeral or burial expenses?

If YES, skip to question 6.

If NO, place an X in the NO box, then go to question 6.

YOU:

NO SPOUSE:

NO

6.Other than your home and the property on which it is located, do you or your spouse, if married and living together, own any real estate? Examples of other real estate are summer homes, rental properties or undeveloped land you own which is separate from your home.

YES

NO

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?

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 X in the ZERO box. Place an X in only one box.

ZERO 1

2

3

4

5

6

7

8

9 or more

Form SSA-1020B-OCR-SM-INST (01-2014) Page 3

DO NOT COMPLETE THIS IS NOT AN APPLICATION.

8.If you or your spouse, if married and living together, receive income from any of the sources listed below, you must answer the questions for both of you. Please enter the total amount you receive each month. If the amount changes from month to month or you do not receive it every month, enter the average monthly income for the past year for each type in the appropriate boxes. Do not list wages and self-employment, interest income, public assistance, medical reimbursements or foster care payments here. If you or your spouse do not receive income from a source listed below, place an X in the NONE box for that source.

 

 

 

 

 

 

 

 

 

Monthly Benefit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

•

Social Security benefits

NONE

$

 

 

 

 

,

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

before deductions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

•

Railroad Retirement benefits

NONE

$

 

 

 

 

,

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

before deductions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

•

Veterans benefits before deductions

NONE

$

 

 

 

 

,

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

•

Other pensions or annuities before

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

deductions. Do not include money

NONE

$

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

,

 

 

 

 

 

 

 

 

 

 

 

you receive from any item you

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

included in question 4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

•

Other income not listed above,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

including alimony, net rental income,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

workers compensation, unemployment,

NONE

$

 

 

 

 

,

 

 

 

 

 

.

 

 

 

 

 

 

private or State disability payments, etc.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Specify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.Have any of the amounts you included in question 8 decreased during the last two years?

YES

NO

If you have worked in the last two years, you need to answer questions 10-14. If you are married and living with your spouse and either one of you has worked in the last two years, you need to answer questions 10-14. Otherwise, skip to question 15.

10.What do you expect to earn in wages before taxes and deductions this calendar year?

YOU:

SPOUSE:

NONE $

NONE $

,

,

.

.

Form SSA-1020B-OCR-SM-INST (01-2014) Page 4

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With regards to the blanks of this precise document, this is what you should do:

1. Whenever submitting the extra help application pdf, be sure to incorporate all important blanks within the relevant form section. It will help to expedite the process, making it possible for your information to be handled quickly and accurately.

Part # 1 of filling out secure ssa gov i1020 start

2. Right after this part is completed, go on to enter the applicable information in these: General Instructions for, and If You Are Assisting Someone Else.

If You Are Assisting Someone Else, If You Are Assisting Someone Else, and General Instructions for of secure ssa gov i1020 start

3. The following portion is about Completing Your Application You, Social Security Administration, Return this application package in, Form SSABOCRSMINST, and Page - fill in each of these fields.

Completing segment 3 in secure ssa gov i1020 start

4. The subsequent part requires your details in the subsequent areas: Application for Extra Help with, WBDOC Exception, State Code, FIRST NAME, LAST NAME, SUFFIX Jr Sr etc, APPLICANTS SOCIAL SECURITY NUMBER, APPLICANTS DATE OF BIRTH, MMDDYYYY, and If you are married and living. Always give all of the needed information to move onward.

Stage # 4 for filling out secure ssa gov i1020 start

5. When you draw near to the conclusion of your document, you'll find several more things to complete. Specifically, If you are married and living, FIRST NAME, LAST NAME, SUFFIX Jr Sr etc, SPOUSES SOCIAL SECURITY NUMBER, SPOUSES DATE OF BIRTH, MMDDYYYY, If your spouse has Medicare does, YES, If you are married and live with, YES, and If you place an X in the YES box must be filled out.

Step no. 5 for filling in secure ssa gov i1020 start

In terms of SPOUSES DATE OF BIRTH and YES, make sure that you do everything correctly here. The two of these could be the most significant ones in this PDF.

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