IRMAA Re-determination Data Collection Screens
Last Updated: 10/02/2006
LnNo |
0 1 |
1 2 3 4 5 6 7 8 2345678901234567890123456789012345678901234567890123456789012345678901234567890 |
1 |
C |
IRMAA INCOME RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) MENU IRSU M07A |
2 |
0 |
|
3 |
l |
|
4 |
u |
|
5 |
m |
|
6 |
n |
*SELECT THE DESIRED FUNCTION: _ |
7 |
* |
1=MAIN MENU |
8 |
o |
2=QUERY MENU |
9 |
n |
3=CALCULATOR. |
10 |
e |
|
11 |
* |
|
12 |
r |
|
13 |
e |
|
14 |
s |
|
15 |
e |
|
16 |
r |
|
17 |
v |
|
18 |
e |
|
19 |
d |
|
20 |
|
|
21 |
|
|
22 |
|
|
23 |
|
|
24 |
|
**************(Line 24 Reserved for Operating Systems Information)*********** |
LnNo |
0 1 |
1 2 3 4 5 6 7 8 2345678901234567890123456789012345678901234567890123456789012345678901234567890 |
1 |
C |
IRMAA INCOME RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) MAIN MENU IRMN M07B |
2 |
0 |
FIELD OFFICE: SSS *UNIT: ______ |
3 |
l |
|
4 |
u |
*BENEFICIARY SSN: _________ |
5 |
m |
|
6 |
n |
*SELECT THE DESIRED OPTION: _ 1=ESTABLISH 2=UPDATE 3=QUERY. |
7 |
* |
|
8 |
o |
*SELECT THE DESIRED FUNCTION: _ |
9 |
n |
1=LIFE CHANGING EVENT 2=TAX INFORMATION 3=MANUAL IRMAA ADJUSTMENT. |
10 |
e |
|
11 |
* |
IF FUNCTION 2 SELECTED (ESTABLISH ONLY) INPUT TAX YEAR (CCYY): ____ |
12 |
r |
IF FUNCTION 3 SELECTED (ESTABLISH ONLY) INPUT PREMIUM YEAR (CCYY): ____ |
13 |
e |
|
14 |
s |
IF APPEAL DETERMINATION, SELECT LEVEL: _ |
15 |
e |
1=RECONSIDERATION 2=ALJ 3=APPEALS COUNCIL 4=COURT CASE. |
16 |
r |
|
17 |
v |
SELECT APPEAL DISPOSITION: _ |
18 |
e |
1=FULLY FAVORABLE REVERSAL 3=DISMISSAL 5=WITHDRAWAL 7=REMAND |
19 |
d |
2=PARTIALLY FAVORABLE REVERSAL 4=AFFIRMATION 6=ABANDON. |
20 |
|
DATE OF APPEAL DETERMINATION (MMDDCCYY): ________ |
21 |
|
REMARKS: ______________________________________________________________________ |
22 |
|
_______________________________________________________________________________ |
23 |
|
|
24 |
|
**************(Line 24 Reserved for Operating Systems Information)*********** |
LnNo |
0 1 |
1 2 3 4 5 6 7 8 2345678901234567890123456789012345678901234567890123456789012345678901234567890 |
1 |
C |
IRMAA LIFE CHANGING EVENT IRLC M07C |
2 |
0 |
SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS |
3 |
l |
|
4 |
u |
|
5 |
m |
*SELECT LIFE CHANGING EVENT: _ |
6 |
n |
1=DEATH OF SPOUSE 5=WORK STOPPED |
7 |
* |
2=MARRIAGE/REMARRIAGE 6=PENSION INCOME LOSS |
8 |
o |
3=DIVORCE 7=INCOME LOSS FROM INCOME PRODUCING PROPERTY |
9 |
n |
4=WORK REDUCTION 8=NON-QUALIFYING EVENT. |
10 |
e |
|
11 |
* |
|
12 |
r |
*DATE OF LIFE CHANGING EVENT (MMCCYY): ______ |
13 |
e |
|
14 |
s |
|
15 |
e |
*SELECT PROOF: _ 1=PROVEN 2=NOT PROVEN 3=PENDING. |
16 |
r |
|
17 |
v |
REMARKS: ______________________________________________________________________ |
18 |
e |
_______________________________________________________________________________ |
19 |
d |
|
20 |
|
DELETE THIS LIFE CHANGING EVENT OCCURRENCE (Y/N): _ |
21 |
|
THIS OCCURRENCE WILL BE DELETED – CONTINUE (Y/N): _ |
22 |
|
ENTER TAX YEAR (CCYY): ____ |
23 |
|
|
24 |
|
**************(Line 24 Reserved for Operating Systems Information)*********** |
LnNo |
0 1 |
1 2 3 4 5 6 7 8 2345678901234567890123456789012345678901234567890123456789012345678901234567890 |
1 |
C |
IRMAA TAX INFORMATION IRMA M07D |
2 |
0 |
SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS |
3 |
l |
TYPE: SSS TAX YEAR: SSSS AGI: SSSSSSSSSSSS- TAX EXEMPT INTEREST: SSSSSSSSSSSS |
4 |
u |
|
5 |
m |
*BENEFICIARY REPORT DATE (MMDDCCYY): ________ *TAX YEAR (CCYY): ____ |
6 |
n |
ADJUSTED GROSS INCOME: ____________- TAX EXEMPT INTEREST: ____________ |
7 |
* |
|
8 |
o |
SELECT SOURCE: _ |
9 |
n |
1=TAX RETURN 3=ESTIMATED TAX DATA |
10 |
e |
2=AMENDED TAX RETURN 4=IRS TAX CORRECTION DATA. |
11 |
* |
|
12 |
r |
*SELECT FILING STATUS: _ |
13 |
e |
1=SINGLE 4=HEAD OF HOUSEHOLD |
14 |
s |
2=MARRIED FILING JOINTLY 5=QUALIFYING WIDOW/WIDOWER |
15 |
e |
3=MARRIED FILING SEPARATELY 6=MARRIED FILING SEPARATELY LIVING APART ALL YEAR. |
16 |
r |
|
17 |
v |
*SELECT PROOF: _ 1=PROVEN 2=NOT PROVEN 3=PENDING. GOOD CAUSE (Y/N): _ |
18 |
e |
REMARKS: ______________________________________________________________________ |
19 |
d |
_______________________________________________________________________________ |
20 |
|
DELETE THIS TAX INFORMATION OCCURRENCE (Y/N): _ |
21 |
|
THIS OCCURRENCE WILL BE DELETED – CONTINUE (Y/N): _ |
22 |
|
|
23 |
|
|
24 |
|
**************(Line 24 Reserved for Operating Systems Information)*********** |
LnNo |
0 1 |
1 2 3 4 5 6 7 8 2345678901234567890123456789012345678901234567890123456789012345678901234567890 |
1 |
C |
IRMAA ATTESTATION OF PENALTY OF PERJURY IRPP M07E |
2 |
0 |
SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS |
3 |
l |
|
4 |
u |
|
5 |
m |
I UNDERSTAND THAT BY SUBMITTING THIS EVIDENCE I AM DECLARING UNDER PENALTY |
6 |
n |
OF PERJURY THAT ALL THE INFORMATION PROVIDED IS TRUE AND CORRECT |
7 |
* |
TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANYONE WHO KNOWINGLY GIVES A |
8 |
o |
FALSE OR MISLEADING STATEMENT ABOUT A MATERIAL FACT OR CAUSES SOMEONE ELSE TO |
9 |
n |
DO SO, COMMITS A CRIME AND MAY BE SENT TO PRISON, OR MAY FACE OTHER PENALTIES, |
10 |
e |
OR BOTH. |
11 |
* |
|
12 |
r |
*APPLICANT ATTESTS THAT ALL INFORMATION PROVIDED IS CORRECT (Y/N): _ |
13 |
e |
|
14 |
s |
|
15 |
e |
|
16 |
r |
|
17 |
v |
|
18 |
e |
|
19 |
d |
|
20 |
|
|
21 |
|
|
22 |
|
|
23 |
|
|
24 |
|
**************(Line 24 Reserved for Operating Systems Information)*********** |
LnNo |
0 1 |
1 2 3 4 5 6 7 8 2345678901234567890123456789012345678901234567890123456789012345678901234567890 |
1 |
C |
IRMAA MANUAL IRMAA ADJUSTMENT IRIA M07F |
2 |
0 |
SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS |
3 |
l |
|
4 |
u |
CURRENT IRMAA DATA |
5 |
m |
PREMIUM YEAR: SSSS TAX YEAR: SSSS FILING STATUS: SSSSSSSSSSSSSSSSSSSSSSSSS |
6 |
n |
AGI: SSSSSSSSSSSS- TAX EXEMPTINTEREST: SSSSSSSSSSSS IRMAA AMOUNT: SSSSSSSSSSSS |
7 |
* |
|
8 |
o |
MANUAL IRMAA INPUT |
9 |
n |
*BENEFICIARY REPORT DATE (MMDDCCYY): ________ TAX YEAR (CCYY): ____ |
10 |
e |
ADJUSTED GROSS INCOME: ____________- TAX EXEMPT INTEREST: ____________ |
11 |
|
|
12 |
r |
SELECT FILING STATUS: _ |
13 |
e |
1=SINGLE 4=HEAD OF HOUSEHOLD |
14 |
s |
2=MARRIED FILING JOINTLY 5=QUALIFYING WIDOW/WIDOWER |
15 |
e |
3=MARRIED FILING SEPARATELY 6=MARRIED FILING SEPARATELY LIVING APART ALL YEAR. |
16 |
r |
|
17 |
v |
PREMIUM YEAR: SSSS |
18 |
e |
SELECT IRMAA AMOUNT: _ |
19 |
d |
0=NO IRMAA 2=LEVEL TWO (SSSS.SS) 4=LEVEL FOUR (SSSS.SS) |
20 |
|
1=LEVEL ONE (SSSS.SS) 3=LEVEL THREE (SSSS.SS). |
21 |
|
|
22 |
|
|
23 |
|
|
24 |
|
**************(Line 24 Reserved for Operating Systems Information)*********** |
LnNo |
0 1 |
1 2 3 4 5 6 7 8 2345678901234567890123456789012345678901234567890123456789012345678901234567890 |
1 |
C |
IRMAA INCOME RELATED MONTHLY ADJUSTMENT AMOUNT RESULTS IRRE M07G |
2 |
0 |
SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS |
3 |
l |
|
4 |
u |
CURRENT IRMAA DATA |
5 |
m |
PREMIUM YEAR: SSSS TAX YEAR: SSSS FILING STATUS: SSSSSSSSSSSSSSSSSSSS |
6 |
n |
AGI: SSSSSSSSSSSS- TAX EXMP INTEREST: SSSSSSSSSSSS IRMAA AMOUNT: SSSSSSSSSSSS |
7 |
* |
RECALCULATED IRMAA DATA |
8 |
o |
PREMIUM YEAR: SSSS TAX YEAR: SSSS FILING STATUS: SSSSSSSSSSSSSSSSSSSS |
9 |
n |
AGI: SSSSSSSSSSSS- TAX EXMP INTEREST: SSSSSSSSSSSS IRMAA AMOUNT: SSSSSSSSSSSS |
10 |
e |
|
11 |
|
CURRENT IRMAA DATA |
12 |
r |
PREMIUM YEAR: SSSS TAX YEAR: SSSS FILING STATUS: SSSSSSSSSSSSSSSSSSSS |
13 |
e |
AGI: SSSSSSSSSSSS- TAX EXMP INTEREST: SSSSSSSSSSSS IRMAA AMOUNT: SSSSSSSSSSSS |
14 |
s |
RECALCULATED IRMAA DATA |
15 |
e |
PREMIUM YEAR: SSSS TAX YEAR: SSSS FILING STATUS: SSSSSSSSSSSSSSSSSSSS |
16 |
r |
AGI: SSSSSSSSSSSS- TAX EXMP INTEREST: SSSSSSSSSSSS IRMAA AMOUNT: SSSSSSSSSSSS |
17 |
v |
|
18 |
e |
NEW DETERMINATION RESULTS: SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS |
19 |
d |
*PROCESS IRMAA ADJUSTMENT (Y/N): _ *PROCESS TAX INFORMATION UPDATE (Y/N): _ |
20 |
|
*PROCESS IRMAA DISMISSAL (Y/N): _ |
21 |
|
*SELECTING “N” WILL CANCEL TRANSACTION - CONTINUE (Y/N): _ |
22 |
|
MORE (Y/N):_ |
23 |
|
|
24 |
|
**************(Line 24 Reserved for Operating Systems Information)*********** |
LnNo |
0 1 |
1 2 3 4 5 6 7 8 2345678901234567890123456789012345678901234567890123456789012345678901234567890 |
1 |
C |
IRMAA PENDING LIFE CHANGING EVENTS IRLP M07H |
2 |
0 |
SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS |
3 |
l |
|
4 |
u |
|
5 |
m |
*SELECT DESIRED EVENT: __ |
6 |
n |
|
7 |
* |
01=REPORT DATE: ________ EVENT: _________________ DATE: ______ APPEAL: _____ |
8 |
o |
02=REPORT DATE: ________ EVENT: _______________ DATE: ______ APPEAL: _____ |
9 |
n |
03=REPORT DATE: ________ EVENT: _________ ______ DATE: ______ APPEAL: _____ |
10 |
e |
04=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____ |
11 |
* |
05=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____ |
12 |
r |
06=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____ |
13 |
e |
07=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____ |
14 |
s |
08=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____ |
15 |
e |
09=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____ |
16 |
r |
10=REPORT DATE: ________ EVENT: _____________ __ DATE: ______ APPEAL: _____ |
17 |
v |
11=REPORT DATE: ________ EVENT: _____________ __ DATE: ______ APPEAL: _____ |
18 |
e |
12=REPORT DATE: ________ EVENT: _____________ __ DATE: ______ APPEAL: _____ |
19 |
d |
13=REPORT DATE: ________ EVENT: _____________ __ DATE: ______ APPEAL: _____ |
20 |
|
|
21 |
|
|
22 |
|
|
23 |
|
|
24 |
|
**************(Line 24 Reserved for Operating Systems Information)*********** |
LnNo |
0 1 |
1 2 3 4 5 6 7 8 2345678901234567890123456789012345678901234567890123456789012345678901234567890 |
1 |
C |
IRMAA LIFE CHANGING EVENT QUERY HISTORY IRLQ M07I |
2 |
0 |
SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS |
3 |
l |
|
4 |
u |
|
5 |
m |
*SELECT DESIRED EVENT: __ |
6 |
n |
|
7 |
* |
01=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____ |
8 |
o |
02=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____ |
9 |
n |
03=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____ |
10 |
e |
04=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____ |
11 |
* |
05=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____ |
12 |
r |
06=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____ |
13 |
e |
07=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____ |
14 |
s |
08=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____ |
15 |
e |
09=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____ |
16 |
r |
10=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____ |
17 |
v |
11=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____ |
18 |
e |
12=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____ |
19 |
d |
13=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____ |
20 |
|
|
21 |
|
|
22 |
|
MORE (Y/N): _ |
23 |
|
|
24 |
|
**************(Line 24 Reserved for Operating Systems Information)*********** |
LnNo |
0 1 |
1 2 3 4 5 6 7 8 2345678901234567890123456789012345678901234567890123456789012345678901234567890 |
1 |
C |
IRMAA PENDING TAX INFORMATION IRTP M07J |
2 |
0 |
SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS |
3 |
l |
|
4 |
u |
|
5 |
m |
*SELECT DESIRED EVENT: __ |
6 |
n |
|
7 |
* |
01=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____ |
8 |
o |
02=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____ |
9 |
n |
03=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____ |
10 |
e |
04=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____ |
11 |
* |
05=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____ |
12 |
r |
06=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____ |
13 |
e |
07=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____ |
14 |
s |
08=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____ |
15 |
e |
09=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____ |
16 |
r |
10=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____ |
17 |
v |
11=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____ |
18 |
e |
12=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____ |
19 |
d |
13=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____ |
20 |
|
|
21 |
|
|
22 |
|
|
23 |
|
|
24 |
|
**************(Line 24 Reserved for Operating Systems Information)*********** |
LnNo |
0 1 |
1 2 3 4 5 6 7 8 2345678901234567890123456789012345678901234567890123456789012345678901234567890 |
1 |
C |
IRMAA TAX INFORMATION QUERY HISTORY IRTQ M07K |
2 |
0 |
SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS |
3 |
l |
|
4 |
u |
|
5 |
m |
*SELECT DESIRED EVENT: __ |
6 |
n |
|
7 |
* |
01=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____ |
8 |
o |
02=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____ |
9 |
n |
03=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____ |
10 |
e |
04=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____ |
11 |
* |
05=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____ |
12 |
r |
06=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____ |
13 |
e |
07=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____ |
14 |
s |
08=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____ |
15 |
e |
09=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____ |
16 |
r |
10=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____ |
17 |
v |
11=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____ |
18 |
e |
12=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____ |
19 |
d |
13=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____ |
20 |
|
|
21 |
|
|
22 |
|
MORE (Y/N): _ |
23 |
|
|
24 |
|
**************(Line 24 Reserved for Operating Systems Information)*********** |
LnNo |
0 1 |
1 2 3 4 5 6 7 82345678901234567890123456789012345678901234567890123456789012345678901234567890 |
1 |
C |
IRMAA INCOME RELATED MONTHLY ADJUSTMENT AMOUNT CALCULATOR IRCA M070 |
2 |
0 |
|
3 |
l |
BENEFICIARY TAX DATA |
4 |
u |
|
5 |
m |
*SELECT FILING STATUS: _ |
6 |
n |
1=SINGLE 4=HEAD OF HOUSEHOLD |
7 |
* |
2=MARRIED FILING JOINTLY 5=QUALIFYING WIDOW/WIDOWER |
8 |
o |
3=MARRIED FILING SEPARATELY 6=MARRIED FILING SEPARATELY LIVING APART ALL YEAR. |
9 |
n |
|
10 |
e |
*PREMIUM YEAR (CCYY): ____ |
11 |
* |
|
12 |
r |
ADJUSTED GROSS INCOME: ____________- TAX EXEMPT INTEREST: ____________ |
13 |
e |
|
14 |
s |
CALCULATOR RESULTS |
15 |
e |
|
16 |
r |
FILING STATUS: _ PREMIUM YEAR (CCYY): ____ MAGI: ____________- |
17 |
v |
|
18 |
e |
MODIFIED ADJUSTED GROSS INCOME RANGE ___________ TO ___________ |
19 |
d |
|
20 |
|
IRMAA LEVEL: _ IRMAA: _______ |
21 |
|
|
22 |
|
|
23 |
|
|
24 |
|
**************(Line 24 Reserved for Operating Systems Information)*********** |
File Type | application/msword |
File Title | LnNo |
Author | 592220 |
Last Modified By | Faye |
File Modified | 2006-10-03 |
File Created | 2006-10-03 |