Form SSA-44 (electronic SSA-44 (electronic Medicare Part B Income-Related Premium -- Life-Changing

Medicare Part B Income-Related Premium -- Life-Changing Event

10-3-06 ssa-44 screen shots

Medicare Part B Income-Related Premium -- Life-Changing Event (screen shots)

OMB: 0960-0735

Document [doc]
Download: doc | pdf

IRMAA Re-determination Data Collection Screens

Last Updated: 10/02/2006

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IRMAA INCOME RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) MENU IRSU M07A

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*SELECT THE DESIRED FUNCTION: _

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1=MAIN MENU

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2=QUERY MENU

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3=CALCULATOR.

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*

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IRMAA INCOME RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) MAIN MENU IRMN M07B

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FIELD OFFICE: ­SSS *UNIT: ______

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*BENEFICIARY SSN: _________

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*SELECT THE DESIRED OPTION: _ 1=ESTABLISH 2=UPDATE 3=QUERY.

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*

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*SELECT THE DESIRED FUNCTION: _

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1=LIFE CHANGING EVENT 2=TAX INFORMATION 3=MANUAL IRMAA ADJUSTMENT.

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IF FUNCTION 2 SELECTED (ESTABLISH ONLY) INPUT TAX YEAR (CCYY): ____

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IF FUNCTION 3 SELECTED (ESTABLISH ONLY) INPUT PREMIUM YEAR (CCYY): ____

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IF APPEAL DETERMINATION, SELECT LEVEL: _

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1=RECONSIDERATION 2=ALJ 3=APPEALS COUNCIL 4=COURT CASE.

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SELECT APPEAL DISPOSITION: _

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1=FULLY FAVORABLE REVERSAL 3=DISMISSAL 5=WITHDRAWAL 7=REMAND

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2=PARTIALLY FAVORABLE REVERSAL 4=AFFIRMATION 6=ABANDON.

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DATE OF APPEAL DETERMINATION (MMDDCCYY): ________

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REMARKS: ______________________________________________________________________

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_______________________________________________________________________________

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LnNo

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IRMAA LIFE CHANGING EVENT IRLC M07C

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SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS

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*SELECT LIFE CHANGING EVENT: _

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1=DEATH OF SPOUSE 5=WORK STOPPED

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2=MARRIAGE/REMARRIAGE 6=PENSION INCOME LOSS

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3=DIVORCE 7=INCOME LOSS FROM INCOME PRODUCING PROPERTY

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4=WORK REDUCTION 8=NON-QUALIFYING EVENT.

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*

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*DATE OF LIFE CHANGING EVENT (MMCCYY): ______

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*SELECT PROOF: _ 1=PROVEN 2=NOT PROVEN 3=PENDING.

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REMARKS: ______________________________________________________________________

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­­­­­­­_______________________________________________________________________________

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DELETE THIS LIFE CHANGING EVENT OCCURRENCE (Y/N): _

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THIS OCCURRENCE WILL BE DELETED – CONTINUE (Y/N): _

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ENTER TAX YEAR (CCYY): ____

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IRMAA TAX INFORMATION IRMA M07D

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SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS

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TYPE: SSS TAX YEAR: SSSS AGI: SSSSSSSSSSSS- TAX EXEMPT INTEREST: SSSSSSSSSSSS

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*BENEFICIARY REPORT DATE (MMDDCCYY): ________ *TAX YEAR (CCYY): ____

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ADJUSTED GROSS INCOME: ____________- TAX EXEMPT INTEREST: ____________

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*

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SELECT SOURCE: _

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1=TAX RETURN 3=ESTIMATED TAX DATA

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2=AMENDED TAX RETURN 4=IRS TAX CORRECTION DATA.

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*

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*SELECT FILING STATUS: _

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1=SINGLE 4=HEAD OF HOUSEHOLD

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2=MARRIED FILING JOINTLY 5=QUALIFYING WIDOW/WIDOWER

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3=MARRIED FILING SEPARATELY 6=MARRIED FILING SEPARATELY LIVING APART ALL YEAR.

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*SELECT PROOF: _ 1=PROVEN 2=NOT PROVEN 3=PENDING. GOOD CAUSE (Y/N): _

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REMARKS: ______________________________________________________________________

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_______________________________________________________________________________

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DELETE THIS TAX INFORMATION OCCURRENCE (Y/N): _

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THIS OCCURRENCE WILL BE DELETED – CONTINUE (Y/N): _

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IRMAA ATTESTATION OF PENALTY OF PERJURY IRPP M07E

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SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS

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I UNDERSTAND THAT BY SUBMITTING THIS EVIDENCE I AM DECLARING UNDER PENALTY

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OF PERJURY THAT ALL THE INFORMATION PROVIDED IS TRUE AND CORRECT

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TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANYONE WHO KNOWINGLY GIVES A

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FALSE OR MISLEADING STATEMENT ABOUT A MATERIAL FACT OR CAUSES SOMEONE ELSE TO

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DO SO, COMMITS A CRIME AND MAY BE SENT TO PRISON, OR MAY FACE OTHER PENALTIES,

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OR BOTH.

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*APPLICANT ATTESTS THAT ALL INFORMATION PROVIDED IS CORRECT (Y/N): _

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IRMAA MANUAL IRMAA ADJUSTMENT IRIA M07F

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SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS

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CURRENT IRMAA DATA

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PREMIUM YEAR: SSSS TAX YEAR: SSSS FILING STATUS: SSSSSSSSSSSSSSSSSSSSSSSSS

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AGI: SSSSSSSSSSSS- TAX EXEMPTINTEREST: SSSSSSSSSSSS IRMAA AMOUNT: SSSSSSSSSSSS

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*

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MANUAL IRMAA INPUT

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*BENEFICIARY REPORT DATE (MMDDCCYY): ________ TAX YEAR (CCYY): ____

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ADJUSTED GROSS INCOME: ____________- TAX EXEMPT INTEREST: ____________

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SELECT FILING STATUS: _

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1=SINGLE 4=HEAD OF HOUSEHOLD

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2=MARRIED FILING JOINTLY 5=QUALIFYING WIDOW/WIDOWER

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3=MARRIED FILING SEPARATELY 6=MARRIED FILING SEPARATELY LIVING APART ALL YEAR.

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PREMIUM YEAR: SSSS

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SELECT IRMAA AMOUNT: _

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0=NO IRMAA 2=LEVEL TWO (SSSS.SS) 4=LEVEL FOUR (SSSS.SS)

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1=LEVEL ONE (SSSS.SS) 3=LEVEL THREE (SSSS.SS).

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IRMAA INCOME RELATED MONTHLY ADJUSTMENT AMOUNT RESULTS IRRE M07G

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SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS

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CURRENT IRMAA DATA

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PREMIUM YEAR: SSSS TAX YEAR: SSSS FILING STATUS: SSSSSSSSSSSSSSSSSSSS

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AGI: SSSSSSSSSSSS- TAX EXMP INTEREST: SSSSSSSSSSSS IRMAA AMOUNT: SSSSSSSSSSSS

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RECALCULATED IRMAA DATA

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PREMIUM YEAR: SSSS TAX YEAR: SSSS FILING STATUS: SSSSSSSSSSSSSSSSSSSS

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AGI: SSSSSSSSSSSS- TAX EXMP INTEREST: SSSSSSSSSSSS IRMAA AMOUNT: SSSSSSSSSSSS

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CURRENT IRMAA DATA

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PREMIUM YEAR: SSSS TAX YEAR: SSSS FILING STATUS: SSSSSSSSSSSSSSSSSSSS

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AGI: SSSSSSSSSSSS- TAX EXMP INTEREST: SSSSSSSSSSSS IRMAA AMOUNT: SSSSSSSSSSSS

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RECALCULATED IRMAA DATA

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PREMIUM YEAR: SSSS TAX YEAR: SSSS FILING STATUS: SSSSSSSSSSSSSSSSSSSS

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AGI: SSSSSSSSSSSS- TAX EXMP INTEREST: SSSSSSSSSSSS IRMAA AMOUNT: SSSSSSSSSSSS

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NEW DETERMINATION RESULTS: SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

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*PROCESS IRMAA ADJUSTMENT (Y/N): _ *PROCESS TAX INFORMATION UPDATE (Y/N): _

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*PROCESS IRMAA DISMISSAL (Y/N): _

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*SELECTING “N” WILL CANCEL TRANSACTION - CONTINUE (Y/N): _

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MORE (Y/N):_

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IRMAA PENDING LIFE CHANGING EVENTS IRLP M07H

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SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS

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*SELECT DESIRED EVENT: __

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01=REPORT DATE: ________ EVENT: _________________ DATE: ______ APPEAL: _____

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02=REPORT DATE: ________ EVENT: _______________ DATE: ______ APPEAL: _____

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03=REPORT DATE: ________ EVENT: _________ ______ DATE: ______ APPEAL: _____

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04=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____

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05=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____

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06=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____

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07=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____

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08=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____

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09=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____

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10=REPORT DATE: ________ EVENT: _____________ __ DATE: ______ APPEAL: _____

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11=REPORT DATE: ________ EVENT: _____________ __ DATE: ______ APPEAL: _____

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12=REPORT DATE: ________ EVENT: _____________ __ DATE: ______ APPEAL: _____

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13=REPORT DATE: ________ EVENT: _____________ __ DATE: ______ APPEAL: _____

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IRMAA LIFE CHANGING EVENT QUERY HISTORY IRLQ M07I

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SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS

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*SELECT DESIRED EVENT: __

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01=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____

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02=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____

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03=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____

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04=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____

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05=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____

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06=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____

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07=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____

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08=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____

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09=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____

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10=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____

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11=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____

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12=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____

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13=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____

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MORE (Y/N): _

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LnNo

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IRMAA PENDING TAX INFORMATION IRTP M07J

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SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS

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*SELECT DESIRED EVENT: __

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01=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____

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02=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____

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03=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____

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04=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____

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05=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____

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06=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____

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07=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____

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08=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____

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09=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____

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10=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____

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11=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____

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12=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____

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13=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____

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IRMAA TAX INFORMATION QUERY HISTORY IRTQ M07K

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SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS

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*SELECT DESIRED EVENT: __

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01=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____

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02=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____

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03=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____

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04=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____

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05=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____

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06=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____

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07=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____

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08=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____

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09=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____

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10=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____

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11=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____

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12=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____

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13=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____

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MORE (Y/N): _

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LnNo

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IRMAA INCOME RELATED MONTHLY ADJUSTMENT AMOUNT CALCULATOR IRCA M070

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0

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BENEFICIARY TAX DATA

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*SELECT FILING STATUS: _

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1=SINGLE 4=HEAD OF HOUSEHOLD

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2=MARRIED FILING JOINTLY 5=QUALIFYING WIDOW/WIDOWER

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3=MARRIED FILING SEPARATELY 6=MARRIED FILING SEPARATELY LIVING APART ALL YEAR.

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*PREMIUM YEAR (CCYY): ____

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*

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ADJUSTED GROSS INCOME: ____________- TAX EXEMPT INTEREST: ____________

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CALCULATOR RESULTS

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FILING STATUS: _ PREMIUM YEAR (CCYY): ____ MAGI: ____________-

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MODIFIED ADJUSTED GROSS INCOME RANGE ___________ TO ___________­

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IRMAA LEVEL: _ IRMAA: _______

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File TitleLnNo
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Last Modified ByFaye
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File Created2006-10-03

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