SSA-1026-SCE SSA - Reporting a Change That May Affect Your Extra Help

Social Security Administration
Reporting A Change That May
Affect Your Extra Help

Because of the report you made to us, we must review your eligibility for Extra Help with
Medicare prescription drug plan costs. We will check that you are still eligible and
that your Extra Help, also known as the subsidy, is correct. We want to make this review as
simple as possible for you, so you will not need to visit the office.
What We Will Do To Review Your Case
As part of the review, we will look at current information in our records. Your continued
eligibility is determined by the amount of your resources, income and household size. If you
have a spouse and you are living together, your total resources and income count.
What You Need To Do For This Review
• Please complete the enclosed form; do not use the form on the Internet website.
• Refer to the Resources and Income Summary on the back of this letter when
completing the form.
• Sign and return the form in the enclosed envelope within 90 days.
If You Do Not Return This Form
If you do not return this form within 90 days, your Extra Help with Medicare prescription drug
plan costs will be terminated. If you are waiting for information from another agency or need
assistance, you can call Social Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778).
If you need assistance, we can give you an additional 30 days to return the form to us.

Enclosures
Form

Social Security Administration

SSA-1026-OCR-SM-SCE (08-2019) Recycle prior editions

Social Security Administration
Resources and Income Summary

Name
Spouse Name
This page shows information we have about your resources and income. Please review the
information below and refer back to this page when completing the enclosed form (SSA-1026):
Resources (see question 5)

Bank accounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Stocks, bonds or other investments . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
Value of real estate other than your home . . . . . . . . . . . . . . . . . . . . . . . .$

Value

Household Size (see question 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Income Not From Work (see question 8)

Social Security benefits before deductions . . . . . . . . . . . . . . . . . . . . . . . $
Railroad Retirement benefits before deductions . . . . . . . . . . . . . . . . . . . $
Veteran’s benefits before deductions . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
Other pensions or annuities before deductions . . . . . . . . . . . . . . . . . . . . $
Other income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$

Earned Income (see question 9)

Monthly Amount

Annual Amount

Wages before taxes and deductions

Yours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
Your spouse’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

Net earnings from self-employment

Yours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
Your spouse’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Net loss from self-employment
Yours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Your spouse’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

Disability Or Blind Work Expenses (see question 10)

Disability work expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
Blind work expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
KEEP THIS PAGE FOR YOUR RECORDS

Form

SSA-1026-OCR-SM-SCE (08-2019)

Monthly Amount

Statement for Continuing Eligibility
for Extra Help with Medicare
Prescription Drug Plan Costs

Please go to the next page
Form

SSA-1026-OCR-SM-SCE (08-2019) Recycle prior editions

Instructions for Completing the Statement
for Continuing Eligibility for Extra Help
with Medicare Prescription Drug Plan Costs
If You Are Assisting Someone Else With This Form

Answer the questions as if that person were completing the form. You must know that
person’s Social Security number and financial information. Also, complete Section B on
page 6.

How To Complete This Form

• Refer to the Resources and Income Summary on the back of the enclosed letter
when completing this form;
• Use BLACK INK only;
• Keep your numbers, Xs and letters inside the boxes; use only CAPITAL letters;
• Do not add any handwritten comments on the form;
• Do not use dollar signs when entering money amounts. The dollar sign is
preprinted; and
• Cents can be rounded to the nearest whole dollar.

Completing Your Form

Please use the enclosed pre-addressed stamped envelope to return your completed and
signed form to:
Social Security Administration
Wilkes-Barre Direct Operations Center
P.O. Box 1080
Wilkes-Barre, PA 18767
The Resources and Income Summary sheet on the back of the enclosed letter will assist you
in completing this form. Do not include the Resources and Income Summary sheet or any
attachments when you return the form in the enclosed postage-paid envelope. If we need
more information, such as statements from financial institutions, we will contact you.

If You Have Questions Or Need Help Completing This Form

You can 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.
Form

SSA-1026-OCR-SM-SCE (08-2019)

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Form Approved
OMB No. 0960-0723

Statement for Continuing Eligibility for Extra Help
with Medicare Prescription Drug Plan Costs
THIS DOES NOT ENROLL YOU IN A
MEDICARE PRESCRIPTION DRUG PLAN.

FOR OFFICIAL USE ONLY
State
Code:

WBDOC
Exception:

1. Name (Print each letter in a separate box.)
MI

FIRST NAME

SUFFIX (JR., SR., ETC.)

LAST NAME
SOCIAL SECURITY NUMBER

DATE OF BIRTH
(MM - DD - YYYY)

MEDICARE NUMBER
(This number is printed on your Medicare card)
2. Spouse’s Name (if you are married and living together)
MI

FIRST NAME
LAST NAME

SUFFIX (JR., SR., ETC.)

SPOUSE’S SOCIAL SECURITY NUMBER

SPOUSE’S DATE OF BIRTH
(MM - DD - YYYY)

SPOUSE’S MEDICARE NUMBER
3. If your marital status has not changed or you already reported the change to us, go to question 4.
If your marital status has changed and you did not report it to us, what is your current marital status?
Married (living together)
Divorced/Widowed/Separated/Annulled
Form

SSA-1026-OCR-SM-SCE (08-2019)

Date of change in marital status:
Page 2

4. If all of the information on the Resources and Income Summary is correct, place an X in the box
and go to question 11 on page 5, sign and return this form.
If any of the information on the Resources and Income Summary is incorrect, continue to
question 5.
5. We need to know about resources that you, your spouse (if married and living together) or both
of you have.
Instructions: Please look at the information we have about your resources on the Resources and
Income Summary on the back of the enclosed letter.
If the information has not changed, place an X in the box and go to question 6.

If the information has changed, fill in the new amount in the boxes below.
Type of Resource

The Correct Amount Is

Bank accounts (checking, savings
and certificates of deposit)

$

,

.

Stocks, bonds, savings bonds, mutual
funds, Individual Retirement Accounts
or other similar investments

$

,

.

Cash

$

,

.

Value of real estate other than your home

$

,

.

6. Will some money from the sources listed in question 5 be used to pay for funeral or burial expenses?
If YES, skip to question 7.
If NO, place an X in the NO box, then go to question 7.

Form

YOU:

NO

SPOUSE:

NO

SSA-1026-OCR-SM-SCE (08-2019)

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7. For this question, a relative is someone related to you by blood, adoption, or marriage (but not
including your spouse). How many relatives live with you and depend on you or your spouse for
at least one-half of their financial support?
Instructions: Please look at the information we have about your household size on the Resources
and Income Summary on the back of the enclosed letter. If the information has not changed,
place an X in the box and go to question 8.
Please do not include yourself or your spouse in the number you enter. If your household
consists only of you or you and your spouse, place an X in the ZERO box. Place an X in only
one box.

ZERO

1

2

3

4

6

5

9 or more

8

7

8. We need to know about income not from work that you, your spouse (if married and living
together) or both of you have from any of the sources listed below.
Instructions: Please look at the information we have about your income not from work on the
Resources and Income Summary on the back of the enclosed letter.
If the information has not changed, place an X in the box and go to question 9.

If the information has changed, fill in the new amount in the boxes below.
The Correct Monthly Amount Is
Social Security benefits before deductions

$

,

.

Railroad Retirement benefits before deductions

$

,

.

Veteran’s benefits before deductions

$

,

.

Other pensions or annuities before deductions.
Do not include money you receive from
any item you included in question 5.

$

,

.

Other income not listed above, including alimony,
net rental income, workers compensation,
unemployment, private or State disability
payments, etc. (Specify):

$

,

.

Form

SSA-1026-OCR-SM-SCE (08-2019)

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9. We need to know about annual earned income from work that you, your spouse (if married
and living together) or both of you have.
Instructions: Please look at the information we have about your earned income on the
Resources and Income Summary on the back of the enclosed letter.
If the information has not changed, place an X in the box and go to question 10.
If the information has changed, fill in the new amount in the boxes below.
Type of Earned Income

The Correct Annual Amount Is

Wages before taxes and deductions

Net earnings from self-employment

Net loss from self-employment

YOU

$

,

.

SPOUSE

$

,

.

YOU

$

,

.

SPOUSE

$

,

.

YOU

$

,

.

SPOUSE

$

,

.

10. Do you, your spouse (if married and living together), or both have to pay for things that enable
you to work (also known as disability or blind work expenses)? We will count only a part of
your earnings toward the income limit if you work and receive Social Security benefits based on
a disability or blindness and you have work-related expenses for which you are not reimbursed.
Examples of such expenses are: the costs of medical treatment and drugs for AIDS, cancer,
depression or epilepsy; a wheelchair; personal attendant services; vehicle modifications, 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:

YES

NO

11. If you or your spouse (if married and living together) work and plan to stop working, enter
month and year. Otherwise sign the form on page 6 and return it to us.

YOU:
SPOUSE:
Form

SSA-1026-OCR-SM-SCE (08-2019)

Page 5

MM

2 0
Y Y Y Y

MM

2 0
Y Y Y Y

Signatures
IMPORTANT INFORMATION - PLEASE READ CAREFULLY
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 (IRS) to make sure the determination is correct.
By submitting this form, 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, benefits, and pensions.
I/We declare 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.
Please complete Section A. If you cannot sign, a representative may sign for you. If someone
assisted you, complete Section B as well.
Section A
Your Signature:

Date:

Spouse's Signature:

Date:

Phone Number:

(

)

Your Mailing Address:

Apt. #:

City:

State:

Zip Code:

If you changed your mailing address within the last three months, place an X in the box:
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.
Phone Number:
Print First Name:
Print Last Name:

(

)

-

Section B
If you are assisting someone else, place an X in the box that describes who you are and provide your daytime
phone number and address.
Family Member

Attorney

Other Advocate

Friend

Agency

Social Worker

Print First Name:

Print Last Name:

Other
Specify:

Phone Number:

(

Address:

SSA-1026-OCR-SM-SCE (08-2019)

Apt. #:

City:

Form

)

State:

Page 6

Zip Code:

Privacy Act / Paperwork Reduction Notice
Section 1860D-14 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 affect your eligibility for the Medicare Prescription Drug Plan (Part D) subsidy.
We will use the information to review and re-determine your eligibility for the Medicare Part D
subsidy. We may also share your information for the following purposes, called routine uses:
1. To applicants, claimants, prospective applicants or claimants (other than the data subjects
and their authorized representatives) to the extent necessary for the purpose of pursuing
Medicare Part D and Part D subsidy entitlement or appeal rights; and
2. To the Centers for Medicare and Medicaid 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.
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.ssa.gov/privacy/sorn.html.
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 18
minutes to read the instructions, gather the facts, and answer the questions. You may
send comments on our time estimate above to: SSA, 6401 Security Blvd., 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, POSTAGE-PAID ENVELOPE:
Social Security Administration
Wilkes-Barre Direct Operations Center
P.O. Box 1080
Wilkes-Barre, PA 18767

Form

SSA-1026-OCR-SM-SCE (08-2019)

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