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

Form Approved
OMB No. 0960-0735

Social Security Administration

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

If you had a major life-changing event that has reduced your income, you may use this
form to request a reduction in your Medicare Part B income-related premium. See
page 5 for detailed information and line-by-line instructions. If you prefer to schedule
an interview with your local Social Security office, then call 1-800-772-1213
(TTY 1-800-325-0778).
Name

Social Security Number

You may use this form if you received a notice that your monthly Medicare Part B premium
includes an income-related monthly adjustment amount and you experienced a life-changing
event that may reduce your income-related monthly adjustment amount. To decide this
amount, we asked the Internal Revenue Service (IRS) about certain income from the Federal
income tax return you filed for the 2008 tax year. If that was not available, we asked for your
tax return information for 2007.
We used your adjusted gross income plus tax-exempt interest income which we call “modified
adjusted gross income.” We took this information and used the table below to decide your
income-related monthly adjustment amount.
The table below shows the income-related monthly adjustment amounts to your Medicare
premium based on your tax filing status and income. If your modified adjusted gross income
was lower than $85,000.01 (or lower than $170,000.01 if you filed your taxes with the filing
status of married, filing jointly) in your most recent filed tax return, you do not have to pay an
income-related monthly adjustment amount. If you do not have to pay an income-related
monthly adjustment amount, you should not fill out this form even if you experienced a lifechanging event.
If you filed your taxes as:
Single,
Head of household,
Qualifying widow(er) with dependent
child, or
Married filing separately (and you
did not live with your spouse in tax
year)*
Married, filing jointly
Married, filing separately (and you lived
with your spouse during part of that tax
year)*

And your modified adjusted
gross income was:

Your income-related
premium is:

$ 85,000.01 - $107,000.00
$107,000.01 - $160,000.00
$160,000.01 - $214,000.00
More than $214,000

$ 44.20
$110.50
$176.80
$243.10

$170,000.01 - $214,000.00
$214,000.01 - $320,000.00
$320,000.01 - $428,000.00
More than $428,000

$ 44.20
$110.50
$176.80
$243.10

$ 85,000.01 - $129,000.00
More than $129,000

$176.80
$243.10

* Let us know if your tax filing status for the tax year was Married, filing separately, but you lived apart
from your spouse at all times during that tax year.
Form SSA-44 (05-2010) Destroy Prior Editions

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STEP 1: Type of Life-Changing Event
Check ONE life-changing event and fill in the date that the event occurred (mm/dd/yyyy). If
you had more than one life-changing event, please call your local Social Security Office at
1-800-772-1213 (TTY 1-800-325-0778)
Marriage
Divorce/Annulment

Work Reduction
Loss of Income-Producing Property

Death of Your Spouse

Loss of Pension Income

Work Stoppage

Employer Settlement Payment

Date of life-changing event: ________________
mm/dd/yyyy
STEP 2: Reduction in Income
Fill in the tax year in which your income was reduced by the life-changing event (see
instructions on page 6), the amount of your adjusted gross income (AGI) and tax-exempt
interest income (if any), and your tax filing status.
Tax-Exempt Interest

Adjusted Gross Income

Tax Year

$ __ __ __ __ __ __.__ __

2 0 __ __

$ __ __ __ __ __ __.__ __

Tax Filing Status for this Tax Year (choose ONE ):
Single
Head of Household
Married, Filing Jointly

Married, Filing Separately

Qualifying Widow(er)
with Dependent Child

STEP 3: Modified Adjusted Gross Income
Will your modified adjusted gross income be lower next year than the year in Step 2?
No – Skip to STEP 4
Yes – Complete the blocks below for next year
Tax Year

Estimated Adjusted Gross Income

Estimated Tax-Exempt Interest

$ __ __ __ __ __ __.__ __

$ __ __ __ __ __ __.__ __

2 0 __ __

Expected Tax Filing Status for this Tax Year (choose ONE ):
Single

Head of Household

Married, Filing Jointly

Married, Filing Separately

Form SSA-44 (05-2010)

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Qualifying Widow(er)
with Dependent Child

STEP 4: Documentation
Provide evidence of your modified adjusted gross income and your life-changing event. You
can either:
1. Attach the required evidence and we will mail your original documents or certified copies
back to you;
OR
2. Show your original documents or certified copies of evidence of your life-changing event
and modified adjusted gross income to an SSA employee.
Note: You must sign in Step 5 and attach all required evidence. Make sure that you provide
your current address and a phone number so that we can contact you if we have any
questions about your request.
STEP 5: Signature
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE SIGNING THIS
FORM.
I understand that the Social Security Administration (SSA) will check my statements with
records from the Internal Revenue Service to make sure the determination is correct.

I declare under penalty of perjury that I have examined the information on this form and
it is true and correct to the best of my knowledge.
I understand that signing this form does not constitute a request for SSA to use more
recent tax year information unless it is accompanied by:
• Evidence that I have had the life-changing event indicated on this form;
• A copy of my Federal tax return; or
• Other evidence of the more recent tax year's modified adjusted gross income.
Signature

Phone Number

Mailing Address

Apartment Number

City

State

Form SSA-44 (05-2010)

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Zip Code

THE PRIVACY ACT
We are required by section 1839(i) of the Social Security Act to ask you to give
us the information on this form. This information is needed to determine if you
qualify for a reduction in the income-related adjustment to your Medicare Part B
premium. In order for us to determine if you qualify, we need to evaluate
information that you provide to us about your modified adjusted gross income.
Although the responses are voluntary, if you do not provide the requested
information we will not be able to consider a reduction in your Medicare Part B
premium.
We rarely use the information you supply for any purpose other than for
determining a potential reduction in premiums. However, the law sometimes
requires us to give out the facts on this form without your consent. We may
release this information to another Federal, State, or local government agency to
assist us in determining your eligibility for a reduction in premiums, if Federal law
requires that we do so, or to do the research and audits needed to administer or
improve our efforts for the Medicare program.
We may also use the information you provide in computer matching programs.
Matching programs compare our records with records kept by other Federal,
state or local government agencies. Information from these matching programs
can be used to establish or verify a person’s eligibility for Federally funded or
administered benefit programs and for repayment of payments or delinquent
debts under these programs.
Explanations about these and other reasons why information you provide us may
be used or given out are available in Systems of Records Notice 60-0321
(Medicare Database File). The Notice, additional information about this form, and
any other information regarding our systems and programs, are available on-line
at www.socialsecurity.gov or at your local 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 45 minutes to read the instructions, gather the facts, and
answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S.
Government agencies in your telephone directory or you may call Social
Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on
our time estimate above to:SSA ,6401 Security Blvd, Baltimore, MD 212356401. Send only comments relating to our time estimate to this address,
not the completed form.
Form SSA-44 (05-2010)

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INSTRUCTIONS FOR COMPLETING FORM SSA-44
Medicare Part B Income-Related Premium Adjustment
Life-Changing Event--Request for Use of More Recent Tax Year Information
You do not have to complete this form in order to ask that we use your information about your
modified adjusted gross income for a more recent tax year. If you prefer, you may call
1-800-772-1213 and speak to a representative from 7 a.m. until 7 p.m. on business days to
request an appointment at one of our field offices. If you are hearing-impaired, you may call
our TTY number, 1-800-325-0778.
Identifying Information
Print your full name and your own Social Security Number as they appear on your Social
Security card. Your Social Security Number may be different from the number on your
Medicare card.
STEP 1
You should choose only one life-changing event on the list. If you experienced more than one
life-changing event, please call your local Social Security office at 1-800-772-1213 (TTY
1-800-325-0778). Fill in the date that the life-changing event occurred. The life-changing
event date must be in the same year or an earlier year than the tax year you ask us to use to
decide your income- related premium adjustment. For example, if we used your 2008 tax
information to determine your income-related monthly adjustment amount for 2010, you can
request that we use your 2009 tax information instead if you experienced a reduction in your
income in 2009 due to a life-changing event that occured in 2009 or an earlier year.
Life-Changing Event

Use this category if...

Marriage

You entered into a legal marriage.

Divorce / Annulment

Your legal marriage ended, and you will not file a
joint return with your spouse for the year.

Death of Your Spouse

Your spouse died.

Work Stoppage or
Reduction

You or your spouse stopped working or reduced the hours
that you work.

Loss of Income-Producing
Property

You or your spouse experienced a loss of income from
income-producing property, that was not at your direction
(e.g., not due to the sale or transfer of the property). This
includes loss of income from real property in a
Presidentially or Gubernatorially-declared disaster area,
destruction of livestock or crops due to natural disaster or
disease, or loss of income from property due to arson, or
loss of investment property due to fraud or theft.

Loss of Pension Income

You or your spouse experienced a scheduled cessation,
termination, or reorganization of an employer's pension
plan.

Employer Settlement Payment

You or your spouse receive a settlement from an employer
or former employer because of the employer's bankruptcy
or reorganization.

Form SSA-44 (05-2010)

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INSTRUCTIONS FOR COMPLETING FORM SSA-44
STEP 2
Supply information about the more recent year's modified adjusted gross income. Note that
this year must reflect a reduction in your income due to the life-changing event you listed in
Step 1. A change in your tax filing status due to the life-changing event might also reduce your
income-related monthly adjustment amount. Your modified adjusted gross income is your
adjusted gross income plus your tax-exempt interest income. We used your modified adjusted
gross income and your tax filing status to set your income-related monthly adjustment amount.
Tax Year
Fill in both empty spaces in the box that says “20_ _ The year you choose
must be more recent than the year of the tax return information we used.
The letter that we sent you tells you what tax year we used.
o Choose this year (the "premium year") - if your modified adjusted gross income is
lower this year than last year. For example, if you request that we adjust your
income-related premium for 2010, use your estimate of your 2010 modified
adjusted gross income if:
1. Your income was not reduced until 2010; or
2. Your income was reduced in 2009, but will be lower in 2010.
o Choose last year (the year before the "premium year," which is the year for which
you want us to adjust your income-related premium) - if your modified adjusted
gross income is not lower this year than last year. For example, if you request
that we adjust your 2010 income-related premium and your income was reduced in
2009 by a life-changing event AND will be no lower in 2010, use your tax
information for 2009.
o Exception: If we used IRS information about your modified adjusted gross
income 3 years before the premium year, you may ask us to use
information from 2 years before the premium year. For example, if we
used your income tax return for 2007 to set your 2010 premium, you can
ask us to use your 2008 information.
If you have any questions about what year you should use, you should call SSA.
Adjusted Gross Income
Fill in your actual or estimated adjusted gross income for the year you wrote in the “tax
year” box. On IRS form 1040, adjusted gross income is the amount on line 37. If you
are providing an estimate, your estimate should be what you expect to enter on your tax
return for that year.
Tax-exempt Interest
Fill in your actual or estimated tax-exempt interest income for the tax year you
wrote in the “tax year” box. On IRS form 1040, tax-exempt interest income is
reported on line 8b. If you are providing an estimate, your estimate should be
what you expect to enter on your tax return for that year.
Filing Status
Check the box in front of your actual or expected tax filing status for the year you wrote in
the “tax year” box.
Form SSA-44 (05-2010)

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INSTRUCTIONS FOR COMPLETING FORM SSA-44
STEP 3
Complete this step only if you expect that your modified adjusted gross income for next year
will be even lower and will reduce your premium below what you told us in Step 2 using the
table on page 1. We will record this information and use it next year to determine your incomerelated Medicare premium. If you do not complete Step 3, we will use the information you
provide in Step 2 next year to determine your income-related Medicare premium, unless one
of the conditions described in “Important Facts” on page 8 occurs.
Tax Year
Fill in both empty spaces in the box that says “20_ _” with the year following the year you
wrote in Step 2. For example, if you wrote "2010" in Step 2, then write "2011" in Step 3.
Adjusted Gross Income
Fill in your estimated adjusted gross income for the year you wrote in the “tax year” box.
On IRS form 1040, adjusted gross income is the amount you expect to enter on line 37
when you file your tax return for that year.
Tax-exempt Interest
Fill in your estimated tax-exempt interest income for the tax year you wrote in the “tax
year” box. On IRS form 1040, tax-exempt interest income is the amount you expect to
report on line 8b.
Filing Status
Check the box in front of your expected tax filing status for the year you
wrote in the “tax year” box.
STEP 4
Provide your required evidence of your modified adjusted gross income and your life-changing
event.
Modified Adjusted Gross Income Evidence
If you have filed your Federal income tax return for the year you wrote in Step 2, then
you must provide us with your signed copy of your tax return or a transcript from IRS. If
you provided an estimate in Step 2, you must show us a signed copy of your tax
return when you file your Federal income tax return for that year.
Life-Changing Event Evidence
We must see original documents or certified copies of evidence that the life-changing
event occurred. Required evidence is described on the next page. In some cases, we
may be able to accept another type of evidence, if you do not have a preferred
document listed on the next page. Ask a Social Security representative to explain what
documentation is accepted.

Form SSA-44 (05-2010)

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Life-Changing
Event

Evidence

Marriage

An original marriage certificate; or a certified copy of a public record of
marriage.

Divorce/Annulment

A certified copy of the decree of divorce or annulment.

Death of Your
Spouse

A certified copy of a death certificate, certified copy of the public record of
death, or a certified copy of a coroner’s certificate.

Work Stoppage or
Reduction

An original signed statement from your employer; copies of pay stubs;
original or certified documents that show a transfer of your business.
Note: In the absence of such proof, we will accept your signed statement,
under penalty of perjury, on this form, that you partially or fully stopped
working or accepted a job with reduced compensation.

Loss of IncomeProducing Property

An original copy of an insurance company adjuster’s statement of loss or
a letter from a State or Federal government about the uncompensated
loss. If the loss was due to investment fraud (theft), we also require proof
of conviction for the theft, such as a court document citing theft or fraud
relating to your or your spouse's loss.

Loss of Pension
Income

A letter or statement from your pension fund administrator that explains
the reduction or termination of your benefits.

Employer Settlement

A letter from the employer stating the settlement terms of the bankruptcy
court and how it affects you or your spouse.

________________________________________________________________________________
STEP 5
Read the information above the signature line, and sign the form. Fill in your phone number and
current mailing address. It is very important that we have this information so that we can contact you
if we have any questions about your request.

____________________________________________________________________________________________________________

Important Facts
•
•
•
•

•

When we use your estimated modified adjusted gross income information to make a decision
about your Medicare Part B premium amount, we will later check with the IRS to verify your report.
If you provide an estimate of your modified adjusted gross income rather than a copy of your
Federal tax return, we will ask you to provide a copy of your tax return when you file your taxes.
If your estimate of your modified adjusted gross income changes, or you amend your tax return for
that reason, you will need to contact us to update our records. If you do not contact us, we may
have to make corrections later including retroactive assessments or refunds of premiums.
We will use your estimate provided in Step 2 to make a decision about the amount of your
Medicare Part B premium the following year until:
o IRS sends us your tax return information for the year used in Step 2; or
o You provide your copy of your filed Federal income tax return or amended Federal income tax
return with a different amount; or
o You provide an updated estimate.
If we used information from IRS about a tax year when your filing status was Married filing
separately, but you lived apart from your spouse at all times during that year, you should
contact us at 1-800-772-1213 (TTY 1-800-325-0778) to explain that you lived apart from your
spouse. Do not use this form to report this change.

Form SSA-44 (05-2010)

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