Application for Help with Medicare Prescription Drug Plan Costs - secure ssa 2025

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The document is an application form for assistance with Medicare Prescription Drug Plan costs. It outlines eligibility criteria based on work history, income expectations, and financial assets. Applicants must provide personal information, including their and their spouse's earnings, Social Security numbers, and any relevant expenses related to work. The form also specifies that those with significant savings or investments may not qualify for extra help.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name as it appears on your Social Security card in the designated fields. Ensure you use one box for each letter.
For questions 12-16, provide accurate information regarding your expected earnings and any relevant work-related expenses. If applicable, indicate if you or your spouse expect a net loss.
If married, complete the spouse's information section, including their name and Social Security number. Make sure to answer whether they wish to apply for extra help.
Review all entries carefully before signing the application on page 6. Ensure that all required fields are filled out correctly to avoid delays.

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