Our records show you may be eligible to get extra help paying for your prescription 

drugs.

Soon, a new Medicare Prescription Drug program will take effect. The new program will 

give you a choice of prescription plans that offer various types of coverage. 

You may be able to get extra help to pay for the annual deductible, premiums and 

co-payments related to the new Medicare Prescription Drug program—an average of 

$2,100 in extra help. 

But before we can help you, you must fi ll out the 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. We also will send you information 

about the Medicare Prescription Drug program and tell you what you should do next. 

If you need help completing the application, call Social Security at 1-800-772-1213

(TTY 1-800-325-0778). You can fi nd more information at www.socialsecurity.gov. 

If you need information about the new Medicare Prescription Drug program, call 

1-800-MEDICARE (TTY 1-877-486-2048) or visit www.medicare.gov. 

Mailing your application today will allow us to give you a quicker decision about whether 

you qualify for the extra help. 

Social Security Administration

Important Information

Form SSA-1020B-OCR-SM SA-1020B-OCR-SM-INST (8-2005)

Jo Anne B. Barnhart

Commissioner 

THIS COVER LETTER IS FOR INFORMATION ONLY.

DO NOT COMPLETE THE FOLLOWING PAGES.

THIS IS NOT AN APPLICATION.
General Instructions for Completing the

Application for Help with Medicare 

Prescription Drug Plan Costs 

To Provide Extra Help in Paying for Your Drug Expenses

Form SSA-1020B-OCR-SM SA-1020B-OCR-SM-INST (8-2005) Page 1

Do you (or the person you are helping apply) have Medicare and 

Supplemental Security Income (SSI) or Medicare and Medicaid or 

does your state pay your Medicare premiums?

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

the extra help. You will receive another letter about how you will receive the extra help. If 

the answer is NO or NOT SURE, please complete this application. Please read the following 

instructions and guidelines before completing this application. Complete all questions unless 

otherwise noted.

How To Complete This Application 

• Use BLACK INK or a #2 pencil;

• Keep your numbers, letters and Xs inside 

the boxes;

• Do not use dollar signs when entering 

money amounts. The dollar sign is 

preprinted; and

• Cents can be rounded to the nearest whole dollar. 

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 fi nancial information. Also, complete Section B on page 6.

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 the entire package in the enclosed envelope. Do not include any attachments. If we 

need more information, such as statements from fi nancial institutions, we will contact you.

If You Have Questions Or Need Help Completing This Application 

You may 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.

EXAMPLE

Put an X in the box. DO NOT fill 

in or use check marks in boxes. 

CORRECT

X

INCORRECT
1. Applicant’s Name (Print each letter in a separate box.)

Page 2

SOCIAL SECURITY NUMBER EXAMPLE 

THIS DOES NOT ENROLL YOU IN THE 

MEDICARE PRESCRIPTION DRUG PROGRAM. 

YES

EXAMPLE

Use capital 

letters when 

entering answers

ABCD

NO NOT SURE

Application for Help with Medicare 

Prescription Drug Plan Costs 

 Applicant’s Social Security Number

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

MI

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

FIRST NAME MI

2. If you are single, divorced, a widow(er) or your spouse does not live with you, skip to 

question 3. If you are married and living with your spouse, please put an in one of the boxes 

below to indicate who is applying:

Even if your spouse is not applying, we need all of the questions answered and 

signatures for both of you if you live together.

Only you are applying.

 Both you and your spouse have Medicare or expect to have it in 

the next three months and are applying on this application.

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

 Spouse’s Social Security Number

3. If you are single, a widow(er) or your spouse does not live with you, are your savings, 

investments and real estate (other than your home) worth more than $11,500? If you are married 

and living together, are they worth more than $23,000? (These limits will be higher after 2006.) 

Include the things you own by yourself, with your spouse or with someone else. Do not include 

your home, vehicles, burial plots or personal possessions. 

Form SSA-1020B-OCR-SM SA-1020B-OCR-SM-INST (8-2005)

FIRST NAME

 If you put an in the YES box, you are not eligible for the extra help and you do not need to 

complete the rest of this application. You may still be eligible through your state Medicaid agency. 

However, if you want a decision, put an in the NOT SURE box. If you put an in either the 

NO or NOT SURE box, complete the rest of this application.

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.
4. Please enter the money amounts of bank accounts, investments or cash that either you, your spouse 

(if married and living together) or both of you own in the boxes below. Include items that either of 

you own with another person. (Include only the dollar fi gures, not the account number.) If you or 

your spouse (if married and living together) do not own an item listed, either separately, jointly or 

with another person, place an in the NONE box.

• Bank accounts (checking, savings and 

certifi cates of deposit) NONE

• Stocks, bonds, savings bonds, mutual 

funds, Individual Retirement Accounts 

or other similar investments

 NONE

• Any other cash at home or anywhere else NONE

5. Do you (or your spouse, if married and living together) own life insurance policies with a total face 

value of more than $1,500? Answer for you and for your spouse if your spouse lives with you. If 

you answered NO for both you and your spouse, go to question 6.

Page 3

YOU: YES NO

SPOUSE (if living together): YES NO

7. 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? 

If you answered YES, how much money would you get if you turned in your policies for cash right 

now? Enter the amount. If you and your spouse both answered YES, enter the combined amount. 

(This is not the face value of your policies. You may need to call your insurance company to help 

answer this question.)

YOU: 

SPOUSE (if living together): YES NO

YES NO

6. Do you expect to use money from any of the sources listed in questions 4 or 5 to pay for funeral or 

burial expenses for yourself (or your spouse, if married and living together)?

YES NO

Form SSA-1020B-OCR-SM SA-1020B-OCR-SM-INST (8-2005)

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.
8. Your living situation may affect the amount of help you can get. Therefore, we need to know how 

many relatives who live with you (and your spouse, if married and living together) depend on you 

or your spouse to provide at least one-half of their fi nancial support. Relatives may include anyone 

related to you by blood, marriage or adoption.

 How many relatives who live with you and your spouse depend on you or your spouse to provide at 

least one-half of their fi nancial support? Do not include yourself or your spouse in this number. 

(Place an in only one box.)

Page 4

NONE 1 2 3 4 5 6 7 8 9 or more

9. If you (or your spouse, if married and living together) receive income from any of the sources listed 

below, please enter the total monthly income. If the amount changes from month to 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 any of the sources 

listed below, place an in the NONE box.

• Social Security We will use the amount in our records.

• Railroad Retirement NONE

• Veterans NONE

• Other pensions or annuities (Do not 

include money you receive from any 

item you included in question 4.)

 NONE

• Other income not listed above, including 

alimony, net rental income, workers’ 

compensation, etc. (Specify):

 ________________________________

 NONE

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

YES NO

11. Does anyone provide or help you (or your spouse, if married and living together) pay for any of the 

following household expenses — food, mortgage, rent, heating fuel or gas, electricity, water and 

property taxes? (Do not include food stamps, house repairs, help from a housing agency, an energy 

assistance program, Meals on Wheels, or help with medical treatment and drugs.) 

YES NO

 If you put an in the YES box, enter the monthly amount 

or, if the amount changes from month to month, enter the 

average monthly amount for the past year.

Form SSA-1020B-OCR-SM SA-1020B-OCR-SM-INST (8-2005)

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.
• If you are single, divorced, separated or a widow(er) and have not worked in 

the last two years, skip questions 12 – 16 and go to page 6.

• If you are married and living with your spouse and neither of you have 

worked in the last two years, skip questions 12 – 16 and go to page 6. 

Page 5

12. What do you expect to earn in wages before taxes this year?

YOU: NONE

SPOUSE (if living together): NONE

13. If self-employed, what do you expect your net earnings or loss to be this year? 

SPOUSE (if living together): NONE

Put an here if you or your spouse expect a net loss. 

14. Have the amounts you included in questions 12 or 13 decreased in the last two years? 

YES NO

15. If you (or your spouse, if married and living together) recently stopped working or plan to stop 

working, enter the month and year.

YOU: 

M M Y Y Y Y 

2 0

SPOUSE :

(if living together) M M Y Y Y Y 

2 0

EXAMPLE

For January – September, 

put a zero (0) in the first 

box. May 2006 should 

read: M M

0 5

Y Y 

2 0

Y Y 

0 6

• If you are single, divorced, separated or a widow(er) and 65 or older, skip 

question 16 and go to page 6.

• If you are married and living with your spouse and both you and your spouse 

are 65 or older, skip question 16 and go to page 6.

16. Do you (or your spouse, if married and living together) have to pay for things that enable you to 

work? We will count only a part of your earnings toward the income limit if you work and receive 

Social Security benefi ts based on a disability or blindness and you have work-related expenses for 

which you are not reimbursed. Examples of such expenses are: the cost of medical treatment and 

drugs for AIDS, cancer, depression, or epilepsy; a wheelchair; personal attendant services; vehicle 

modifi cations, 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 (if living together): YES NO

Form SSA-1020B-OCR-SM SA-1020B-OCR-SM-INST (8-2005)

YOU: NONE

YOU: SPOUSE (if living together): 

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.
I/We understand that by submitting this application I am/we are declaring 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. 

I/We understand that anyone who knowingly gives a false or misleading statement about a material fact in 

this information, or causes someone else to do so, commits a crime and may be sent to prison or may face 

other penalties, or both. 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 to make sure the determination is correct. By submitting this 

application 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, insurance 

policies, benefi ts, and pensions. Please complete Section A. If you cannot sign, a representative may sign 

for you. If someone assisted you, complete Section B as well. 

Signatures

Page 6

SECTION A

If you recently changed your address, put an here: 

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.

Your Home Street Address: Apt. #:

City: State: Zip Code:

Your Mailing Street Address (if different from home address): Apt. #:

City: State: Zip Code:

Your Signature: Your Spouse’s Signature: 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. 

Other 

Specify: _______________

Agency ______________________

Attorney

Social Worker

Other Advocate

Friend

Family Member

Street Address: Apt. #:

City: State: Zip Code:

Print First Name: Print Last Name: Phone Number:

Form SSA-1020B-OCR-SM SA-1020B-OCR-SM-INST (8-2005)

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.
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 to determine if you are 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 application. We may provide information 

collected on this form to another Federal, State, or local government agency to assist us 

in determining your eligibility for the extra help or if a Federal law requires the release 

of information.

We may also 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 fi nd or prove that 

a person qualifi es for benefi ts 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 

offi ces. If you want to learn more about this, contact any Social Security offi ce.

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 Offi ce 

of Management and Budget control number. We estimate that it will take about 35 

minutes to read the instructions, gather the facts, and answer the questions. You may send 

comments on our time estimate above to: Social Security Administration, 1338 Annex 

Building, 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 ENVELOPE:

Social Security Administration

Wilkes-Barre Data Operations Center

P.O. Box 1020

Wilkes-Barre, PA 18767-9910

Privacy Act / Paperwork Reduction Notice

Form SSA-1020B-OCR-SM SA-1020B-OCR-SM-INST (8-2005) Page 7

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.