Ssa-9303

INFORMATION NEEDED FOR REVIEW OF THE APPLICATION FOR HELP WITH
MEDICARE PRESCRIPTION DRUG PLAN COSTS
Please have the INFORMATION CHECKED BELOW on hand for the telephone review.
Even if you do not have all of the information that is checked, I will help you get the
information you do not have. We only need information about your spouse if you and
your spouse were living together when you filed your application.

A. FAMILY SIZE AND HOUSEHOLD EXPENSES INFORMATION
Names, income amount and relationship of any relatives (by blood, marriage or
adoption) living with you and your spouse for whom you and/or your spouse
provide half of their support.
If you are living with anyone other than your spouse and/or minor children, have
their name and amount they contribute towards the household expenses.
The monthly amount you paid for each one of the following items: food,
mortgage/ rent, property insurance, property tax, heating fuel, electricity, gas,
water, garbage removal, and sewer for the time period
.
B. INCOME
Amount of wages that you or your spouse earned during the period
The monthly amount of any pensions, or other benefit (other than Social Security
benefits) you or your spouse receives.
C. RESOURCES
Balance in bank accounts during the period
for all accounts on which your
name and/or your spouse’s name appear as individual or joint owner, or as a
beneficiary.
Value of stocks, bonds, promissory notes, etc. owned by you or your spouse.
Location of property owned by you or your spouse other than the home you live
in.
Amount in retirement savings accounts such as 401K, IRA, KEOGH, etc., owned
by you or your spouse.
D. OTHER

Checklist of Required Information
SSA-9304 (10-2009)

PRIVACY ACT STATEMENT
COLLECTION AND USE OF INFORMATION

See Revised Privacy Act
Statement

Section 1860 D-14 of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide, along with the information we receive from
other people we interview, to conduct a quality review of applications and determine if we made
the correct decision during the review process for those applicants who requested extra help
with Medicare prescription drug costs.
The information you furnish on this form is voluntary. However, failure to provide all or part of
the spousal information could prevent us from making an accurate and timely decision regarding
your eligibility and appeal rights.
HOW THE INFORMATION IS USED
We rarely use the information you provided on this form for any other purpose other than the
reasons explained above. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following:
1. To enable a third party or agency to assist Social Security in establishing rights to
Medicare benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office and Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs
at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity of Social Security programs.
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 and administered benefit programs and for repayment of
payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in System of Records Notice,
entitled, Medicare Database (MDB) File, 60-0321. The notice, additional information regarding
this form, and information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at your local Social Security office.
Checklist of Required Information
SSA-9304 (10-2009)

SSA will insert the following revised Privacy Act Statement into the form as soon as
possible:
Privacy Act Statement
Collection and Use of Personal Information

Section 1860D-14A of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from evaluating the denial of your Medicare Part D subsidy request.
We will use the information to make a determination of eligibility or continued eligibility for
benefits. We may also share your information for the following purposes, called routine uses:
1. To the Centers for Medicare & Medicare Services, for the purpose of administering
Medicare Part D enrollment and premium collection and Medicare Advantage Part C
premium collections, as well as Medicare Part B income-related monthly adjustment
amounts; and
2. To Federal and State agencies administering Medicare Part D and Part D subsidy under
the Medicare Prescription Drug Improvement and Modernization Act of 2003.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0321, entitled Medicare Database File. Additional information and a full listing of
all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.