Ssa 1026 Form – Fill Out and Use This PDF

The SSA-1026 form, officially termed as the Social Security Administration Review of Your Eligibility for Extra Help, is a crucial document designed to assess and confirm an individual's eligibility for Extra Help with Medicare prescription drug plan costs. This form plays a significant role in ensuring that eligible individuals continue to receive the necessary support with their Medicare prescription costs without the need to visit a Social Security office. Individuals are requested to complete and return the enclosed form, referring to the Resources and Income Summary for accurate completion, to maintain their Extra Help benefits. Ensure your benefits are uninterrupted by clicking the button below to complete the SSA-1026 form today.

Get Form Now Download PDF

Ssa 1026 Form PDF Details

When it comes to navigating the complexities of Medicare and ensuring that individuals have the support they need to afford prescription drug plans, the SSA-1026 form plays a critical role. This document, officially termed "Social Security Administration Review of Your Eligibility for Extra Help," serves as a pivotal checkpoint for individuals currently benefiting from—or applying to benefit from—Extra Help with Medicare prescription drug plan costs. This form is not just another piece of paperwork; it is an essential tool used by the Social Security Administration (SSA) to review and confirm an individual's eligibility for financial assistance with these costs. By assessing resources, income, and household size, the SSA ensures that the support provided accurately reflects the current needs of the recipient. From clarifying that this is not an application for new benefits but a review process for existing beneficiaries, to providing detailed guidance on how to complete the form—including avoiding internet versions, using black ink, and rounding cents to the nearest dollar—the SSA-1026 form outlines a straightforward path for individuals to maintain their Extra Help benefits. Crucially, the form underscores the importance of timely submission, warning that failure to return the completed form within 30 days could result in the termination of benefits. This stresses the urgency and significance of the review process, highlighting the direct impact it can have on an individual's access to affordable medication.

Question	Answer
Form Name	Ssa 1026 Form
Form Length	10 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 30 sec
Other names	ssa 1026 ocr sm rede, extra form 1026, ssa sm rede, form ssa 1026 0cr sm rede

Form Preview Example

Social Security Administration

Review Of Your Eligibility For

Extra Help

THIS COVER LETTER IS FOR INFORMATION ONLY.

DO NOT COMPLETE THE FOLLOWING PAGES.

THIS IS NOT AN APPLICATION.

We must review your eligibility for Extra Help with Medicare prescription drug plan costs. We will check to be sure that you are still eligible and that your Extra Help, also known as

the subsidy, is correct. We want to make this review as simple as possible for you, so you will not need to visit the office.

What We Will Do To Review Your Case

As part of the review, we will look at current information in our records. Your continued eligibility is determined by the amount of your resources, income and household size. If you have a spouse and you are living together, your total resources and income count.

What You Need To Do For This Review

•Please complete the enclosed form; do not use the form on the Internet website.

•Refer to the Resources and Income Summary on the back of this letter when completing the form.

•Sign and return the form in the enclosed envelope within 30 days.

If You Do Not Return This Form

If you do not return this form within 30 days, your help with Medicare prescription drug plan costs will be terminated. If you are waiting for information from another agency or need assistance, you can call Social Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778). If you do need assistance, we can give you an additional 30 days to return the form to us.

Social Security Administration

Enclosures

Form SSA-1026B-OCR-SM-INST (08-2012) Recycle prior editions

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.

Social Security Administration

Resources and Income Summary

Name

Spouse Name

Refer to these figures when completing the enclosed form (SSA-1026):

Resources (see question 5)

Value

Bank accounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Stocks, bonds or other investments . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Value of real estate other than your home . . . . . . . . . . . . . . . . . . . . . . . .

Household Size (see question 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Income Not From Work (see question 8)

Monthly Amount

Social Security benefits before deductions . . . . . . . . . . . . . . . . . . . . . . .

Railroad Retirement benefits before deductions . . . . . . . . . . . . . . . . . . .

Veteran’s benefits before deductions . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other pensions or annuities before deductions . . . . . . . . . . . . . . . . . . . .

Other income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Earned Income (see question 9)	Annual Amount
Wages before taxes and deductions
Yours
Yours
Your spouse’s
Your spouse’s
Net earnings from self-employment
Yours
Yours
Your spouse’s
Your spouse’s
Net loss from self-employment
Yours
Yours
Your spouse’s
Your spouse’s
Disability Or Blind Work Expenses (see question 10)	Monthly Amount
Disability work expenses
Disability work expenses
Blind work expenses
Blind work expenses

KEEP THIS PAGE FOR YOUR RECORDS

Form SSA-1026B-OCR-SM-INST (08-2012)

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.

Statement for Continuing Eligibility

for Extra Help with Medicare

Prescription Drug Plan Costs

Please go to the next page

Form SSA-1026B-OCR-SM-INST (08-2012) Recycle prior editions

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.

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 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.

E X A M P L E

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

X
C O R R E C T	I N C O R R E C T

Completing Your Form

E X A M P L E

Use capital letters when entering answers

A B C D

Please use the enclosed pre-addressed stamped envelope to return your completed and signed form to:

Social Security Administration

Wilkes-Barre Data 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-1026B-OCR-SM-INST (08-2012) Page 1

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.

Statement for Continuing Eligibility for Extra Help

with Medicare Prescription Drug Plan Costs

THIS DOES NOT ENROLL YOU IN A

MEDICARE PRESCRIPTION DRUG PLAN.

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

FIRST NAME

LAST NAME

SOCIAL SECURITY NUMBER

SUFFIX (JR., SR., ETC.)

DATE OF BIRTH

(MM - DD - YYYY)

MEDICARE CLAIM NUMBER

(This number is printed on your Medicare card)

E X A M P L E

For January- September put a zero (0) in the ﬁrst box. May 20, 1935 should read:

0	5	2	0	1	9	3	5
	M
M	M	D	D	Y Y Y Y

2.Spouse’s Name (if you are married and living together)

FIRST NAME

LAST NAME

SPOUSE’S SOCIAL SECURITY NUMBER

SPOUSE’S MEDICARE CLAIM NUMBER

SUFFIX (JR., SR., ETC.)

SPOUSE’S DATE OF BIRTH

(MM - DD - YYYY)

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

Date of change in marital status:

Form SSA-1026B-OCR-SM-INST (08-2012) Page 2

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.

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

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?

If YES, skip to question 7.

If NO, place an in the NO box, then go to question 7.

YOU: NO

SPOUSE: NO

Form SSA-1026B-OCR-SM-INST (08-2012) Page 3

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.

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

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.

The Correct Monthly Amount Is

Social Security benefits before deductions

Railroad Retirement benefits before deductions

Veteran’s benefits before deductions

Other pensions or annuities before deductions. Do not include money you receive from

any item you included in question 5.

Other income not listed above, including alimony, net rental income, workers compensation, unemployment, private or State disability payments, etc. (Specify):

Form SSA-1026B-OCR-SM-INST (08-2012) Page 4

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.

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.

YOU:		YES		NO	SPOUSE:		YES		NO

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.

E X A M P L E

For January – September, put a zero (0) in the

ﬁrst box. May 2012 should read:

0	5		2	0	1	2
M	M		Y Y Y Y

YOU:

SPOUSE:

		2	0
		2	0
M	M	Y Y Y Y

		2	0
		2	0
M M		Y Y Y Y

Form SSA-1026B-OCR-SM-INST (08-2012) Page 5

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.

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

Your Signature:	Date:	Phone Number:
Spouse’s Signature:	Date:
Spouse’s Signature:	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 in the box that describes who you are and provide your daytime phone number and address.

Family Member

Attorney

Other Advocate

Other

Specify:

Friend

Agency

Social Worker

Print First Name:

Print Last Name:

Phone Number:

Address:

Apt. #:

City:

State:

Zip Code:

Form SSA-1026B-OCR-SM-INST (08-2012) Page 6

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.

Privacy Act / Paperwork Reduction Notice

Section 1860 D-14 of the Social Security Act authorizes the collection of information requested on this form. The information you provide will be used to enable the Social Security Administration (SSA) to determine if you continue to be eligible for help paying your share of the cost of a Medicare prescription drug plan. You do not have to give us the information requested. However, if you do not provide the information, we

will be unable to make an accurate and timely decision on your continuing eligibility for benefits and could result in the loss of your Extra Help with Medicare prescription

drug plan costs. We may provide information collected on this form to another Federal, State, or local government agency to assist us in determining your initial or continuing eligibility for the Extra Help or if a Federal law requires the release of the information. We also may need to share the information with other SSA programs if SSA needs to determine your eligibility in those programs.

We also may use the information you give us when we match records by computer.

Matching programs compare our records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to

do this even if you do not agree to it. Explanations about these and other reasons why

information you provide us may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office.

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 Data Operations Center

P.O. Box 1080

Wilkes-Barre, PA 18767

Form SSA-1026B-OCR-SM-INST (08-2012) Page 7

How to Edit Ssa 1026 Form Online for Free

When working in the online PDF editor by FormsPal, you can easily fill out or change social ssaocrsm right here and now. We are dedicated to giving you the best possible experience with our editor by constantly introducing new capabilities and improvements. With these improvements, using our editor gets better than ever! All it takes is several easy steps:

Step 1: Hit the orange "Get Form" button above. It'll open up our pdf editor so you can start filling in your form.

Step 2: With our advanced PDF tool, you may do more than simply fill out blank form fields. Edit away and make your forms appear great with custom textual content added in, or optimize the original input to perfection - all that accompanied by an ability to add stunning photos and sign the document off.

When it comes to fields of this particular form, here is what you should know:

1. Begin completing your social ssaocrsm with a selection of major blanks. Note all the required information and ensure there is nothing omitted!

2. Soon after this section is done, go to type in the applicable information in all these - Net earnings from selfemployment, Yours, Your spouses, Net loss from selfemployment, Yours, Your spouses, Disability Or Blind Work Expenses, Monthly Amount, Disability work expenses, Blind work expenses, Form SSABOCRSMINST, and KEEP THIS PAGE FOR YOUR RECORDS.

Yours, Form SSABOCRSMINST, and Your spouses in ssa 1026 ocr

Many people generally make errors when filling in Yours in this section. You should definitely go over what you enter right here.

3. This next part focuses on Name Print each letter in a, FIRST NAME, LAST NAME, SUFFIX JR SR ETC, SOCIAL SECURITY NUMBER, DATE OF BIRTH MM DD YYYY, E X A M P L E, MEDICARE CLAIM NUMBER This number, For January September put a zero, M M D D Y Y Y Y, Spouses Name if you are married, and FIRST NAME - complete all these fields.

4. All set to fill in this next part! Here you'll get all these LAST NAME, SUFFIX JR SR ETC, SPOUSES SOCIAL SECURITY NUMBER, SPOUSES DATE OF BIRTH, MM DD YYYY, SPOUSES MEDICARE CLAIM NUMBER, If your marital status has not, If your marital status has changed, Married living together, DivorcedWidowedSeparatedAnnulled, Date of change in marital status, Form SSABOCRSMINST, and Page fields to fill in.

How you can complete ssa 1026 ocr step 4

5. Since you approach the conclusion of this document, you will find several more requirements that should be fulfilled. In particular, and go to question on page sign, If any of the information on the, We need to know about resources, of you have, Instructions Please look at the, If the information has not changed, in the box and go to question, If the information has changed, Type of Resource, The Correct Amount Is, and Bank accounts checking savings and must be filled in.

Stage number 5 in submitting ssa 1026 ocr

Step 3: Make sure your details are accurate and click on "Done" to complete the process. Try a 7-day free trial plan at FormsPal and acquire immediate access to social ssaocrsm - downloadable, emailable, and editable from your personal cabinet. FormsPal offers risk-free document tools devoid of personal information recording or distributing. Feel comfortable knowing that your data is safe here!

Ssa 1026 Form – Fill Out and Use This PDF

Ssa 1026 Form PDF Details

Form Preview Example

How to Edit Ssa 1026 Form Online for Free

Ssa 1026 Form isn’t the one you’re looking for?

Related Documents