Form SSA-44, Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event Instructions
This form contains 54 fields organized into 13 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Anticipated Income Reduction Confirmation | ||
| No - Skip to STEP 4 | Checkbox |
Check this box if your modified adjusted gross income is NOT expected to be lower next year than the income reported in Step 2, and you should skip to Step 4. Fill only if 'Adjusted Gross Income' is reported in Step 2
Depends on:
Adjusted Gross Income
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| Yes - Complete the blocks below for next year | Checkbox |
Check this box if your modified adjusted gross income IS expected to be lower next year than the income reported in Step 2, and then complete the financial blocks provided for next year. Fill only if 'Adjusted Gross Income' is reported in Step 2
Depends on:
Adjusted Gross Income
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| Applicant Information | ||
| Applicant Name | Text |
Please enter the full name of the applicant.
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| Applicant Social Security Number | Text |
Please enter the applicant's Social Security Number.
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| Expected Tax Filing Status | ||
| Step 3 - Single | Checkbox |
Check this box if you expect to file as Single for the anticipated tax year. Fill only if the 'Step 3 - Yes - Complete the blocks below for next year' is Yes. Fill only if 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Yes - Complete the blocks below for next year
|
| Step 3 - Married, Filing Jointly | Checkbox |
Check this box if you expect to file as Married, Filing Jointly for the anticipated tax year. Fill only if the 'Step 3 - Yes - Complete the blocks below for next year' is Yes. Fill only if 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Yes - Complete the blocks below for next year
|
| Step 3 - Head of Household | Checkbox |
Check this box if you expect to file as Head of Household for the anticipated tax year. Fill only if the 'Step 3 - Yes - Complete the blocks below for next year' is Yes. Fill only if 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Yes - Complete the blocks below for next year
|
| Step 3 - Married, Filing Separately | Checkbox |
Check this box if you expect to file as Married, Filing Separately for the anticipated tax year. Fill only if the 'Step 3 - Yes - Complete the blocks below for next year' is Yes. Fill only if 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Yes - Complete the blocks below for next year
|
| Step 3 - Qualifying Widow(er) with Dependent Child | Checkbox |
Check this box if you expect to file as Qualifying Widow(er) with Dependent Child for the anticipated tax year. Fill only if the 'Step 3 - Yes - Complete the blocks below for next year' is Yes. Fill only if 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Yes - Complete the blocks below for next year
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| Life-Changing Event Details | ||
| Marriage | Checkbox |
Check this box if you experienced a marriage.
|
| Divorce/Annulment | Checkbox |
Check this box if you experienced a divorce or annulment.
|
| Death of Your Spouse | Checkbox |
Check this box if your spouse died.
|
| Work Stoppage | Checkbox |
Check this box if you experienced a work stoppage.
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| Work Reduction | Checkbox |
Check this box if you experienced a reduction in work.
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| Loss of Income-Producing Property | Checkbox |
Check this box if you experienced a loss of income-producing property.
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| Loss of Pension Income | Checkbox |
Check this box if you experienced a loss of pension income.
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| Employer Settlement Payment | Checkbox |
Check this box if you received an employer settlement payment.
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| Date(s) of Life-Changing Event | Date |
Please enter the date(s) when the life-changing event occurred. Fill only if 'Marriage', 'Divorce/Annulment', 'Death of Your Spouse', 'Work Stoppage', 'Work Reduction', 'Loss of Income-Producing Property', 'Loss of Pension Income', 'Employer Settlement Payment' is 'Yes' for any.
Depends on:
Marriage, Divorce/Annulment, Death of Your Spouse, Work Stoppage, Work Reduction, Loss of Income-Producing Property, Loss of Pension Income, Employer Settlement Payment
|
| Mailing Address | ||
| Mailing Address Line 1 | Text |
Please enter the primary street address for the mailing address.
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| Apartment Number | Text |
Please enter the apartment, unit, or suite number for the mailing address.
|
| City | Text |
Please enter the city for the mailing address.
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| State | Text |
Please enter the state for the mailing address.
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| ZIP Code | Text |
Please enter the five-digit or nine-digit ZIP code for the mailing address.
|
| Next Year Income Estimates | ||
| Next Year Tax Year | Text |
Please enter the last two digits of the tax year for which you are providing income estimates. Fill only if 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Yes - Complete the blocks below for next year
|
| Estimated Adjusted Gross Income | Number |
Please provide your estimated adjusted gross income for the next tax year. Fill only if 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Yes - Complete the blocks below for next year
|
| Estimated Tax-Exempt Interest | Number |
Please provide your estimated tax-exempt interest income for the next tax year. Fill only if 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Yes - Complete the blocks below for next year
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| Privacy Act Statement | ||
| Page 4 of 8. THE PRIVACY ACT We are required by sections 1839(i) and 1860D-13 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 your monthly Medicare Part B and/or prescription drug coverage income related monthly adjustment amount (IRMAA). 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 IRMAA. We rarely use the information you supply for any purpose other than for determining a potential reduction in IRMAA. 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 your IRMAA, 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. We will also compare the information you give us to your tax return records maintained by the IRS. The law allows us to do this even if you do not agree to it. 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 1-800-7 7 2-1213 (TTY 1-800-3 2 5-0778). You may send comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD 2 1 2 3 5- 6 4 0 1. Send only comments relating to our time estimate to this address, not the completed form | Text |
This section provides information about the Privacy Act and how your information will be used when you submit this form. It explains the legal requirements for providing your information, how it will be used to determine eligibility for a reduction in your Medicare IRMAA, and the potential sharing of your information with other government agencies. It also includes details about the Paperwork Reduction Act and where to send the completed form.
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| Page 5 of 8. INSTRUCTIONS FOR COMPLETING FORM SSA-44 Medicare Income Related Monthly Adjustment Amount 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 1-800-7 7 2-1213 and speak to a representative from 7 ay 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 T T Y number, 1-800-3 2 5-0778. 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 2023 tax information to determine your income-related monthly adjustment amount for 2025, you can request that we use your 2024 tax information instead if you experienced a reduction in your income in 2024 due to a life-changing event that occurred in 2024 or an earlier year. Below is a table with 2 columns and 7 rows. Column headers are Life Changing Event and Use this category if... Row 1 Marriage, Use this category if you entered into a legal marriage. Row 2 Divorce/Annulment Use this category if your legal marriage ended, and you will not file a joint return with your spouse for the year. Row 3 Death of your spouse Use this category if your spouse died. row 4 Work Stoppage or reduction Use this category if you or your spouse stopped working or reduced the hours that you work. Row 5 Loss of Income Producing Property Use this category if you or your spouse experienced a loss of 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 real property in a Presidentially or Gubernatorially declared disaster area, destruction of livestock or crops due to natural disaster or disease, or loss of property due to arson, or loss of investment property due to fraud or theft. Row 6 loss of Pension Income Use this category if you or your spouse experienced a scheduled cessation, termination, or reorganization of an employer's pension plan. Row 7 Employer Settlement Payment Use this category if you or your spouse receive a settlement from an employer or former employer because of the employer's bankruptcy or reorganization | Text |
This section provides instructions for completing the SSA-44 form, which is used to request a reduction in the Medicare Income-Related Monthly Adjustment Amount (IRMAA) due to a life-changing event. It includes guidance on how to report your modified adjusted gross income for a more recent tax year and how to choose the appropriate life-changing event category. You should print your full name and Social Security Number as they appear on your Social Security card. If you have experienced more than one life-changing event, contact your local Social Security office.
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| Signature and Phone Number | ||
| Signature | Text |
Enter your legal signature to confirm understanding and agreement with the form's statements.
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| Phone Number | Text |
Provide a phone number where you can be contacted if there are any questions regarding your request.
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| STEP 1 | ||
| Page 6 of 8. Instructions for completing Form SSA-44 Step 2 Supply information about the more recent year's modified adjusted gross income (MAGI). Note that this year must reflect a reduction in your income due to the life changing event you listed in Step 1. Ay change in your tax filing status due to the life changing event might also reduce your income related monthly adjustment amount. Your M Ay G I is your adjusted gross income as used on line 11 of IRS form 1040 plus your tax exempt interest income as used on line 2 ay of IRS form 1040. We used your M Ay G I and your tax filing status to determine 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. • 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 2025, use your estimate of your 2025 M Ay G I if: 1. Your income was not reduced until 2025; or 2. Your income was reduced in 2024, but will be lower in 2025. • Choose last year (the year before the "premium year," which is the year for which you want us to adjust your I R M Ay Ay) - if your M Ay G I is not lower this year than last year. For example, if you request that we adjust your 2025 income-related monthly adjustment amounts and your income was reduced in 2024 by a life-changing event AND will be no lower in 2025, use your tax information for 2024. • Exception: If we used IRS information about your M Ay G I 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 2022 to decide your 2025 I R M Ay Ay, you can ask us to use your 2023 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. Adjusted gross income is the amount on line 11 of IRS form 1040. 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 Income • Fill in your actual or estimated tax exempt interest income for the tax year you wrote in the “tax year” box. Tax exempt interest income is the amount reported on line 2 ay of IRS form 1040. 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 | Text |
Provide information about your modified adjusted gross income (MAGI) for a more recent year that reflects a reduction in income due to a life-changing event. Include your adjusted gross income from line 11 of IRS form 1040 and your tax-exempt interest income from line 2a of IRS form 1040. Specify the tax year, which must be more recent than the year of the tax return information previously used by SSA. Choose the appropriate year based on whether your income was reduced in the current or previous year. If unsure, contact SSA for guidance. Fill only if 'Type of Life-Changing Event' is 'Yes'.
Depends on:
Marriage, Divorce/Annulment, Death of Your Spouse, Work Stoppage, Work Reduction, Loss of Income-Producing Property, Loss of Pension Income, Employer Settlement Payment
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| Page 7 of 8. Instructions for completing form SSA-44 Step 3 Complete this step only if you expect that your M Ay G I for next year will be even lower and will reduce your I R M Ay Ay 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 Medicare income-related monthly adjustment amounts. If you do not complete Step 3, we will use the information from Step 2 next year to determine your income-related monthly adjustment amounts, 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 "2025" in Step 2, then write "2026" in Step 3. Adjusted Gross Income • Fill in your estimated adjusted gross income for the year you wrote in the “tax year” box. Adjusted gross income is the amount you expect to enter on line 11 of IRS form 1040 when you file your tax return for that year. Tax exempt Interest Income • Fill in your estimated tax exempt interest income for the tax year you wrote in the “tax year” box. Tax exempt interest income is the amount you expect to report on line 2 ay of IRS form 1040. 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 M Ay G I 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 documents can be accepted | Text |
This field is for entering your estimated adjusted gross income and tax-exempt interest income for the next tax year, as well as selecting your expected tax filing status. This information is used to determine your Medicare income-related monthly adjustment amounts for the following year. Ensure you fill in the year following the one you reported in Step 2, and provide accurate estimates based on your expected IRS Form 1040 entries.
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| STEP 4 | ||
| Page 8 of 8. Below is a table with 2 columns and 7 rows. Column headers are Life Changing Event and Evidence. Row 1 Marriage Evidence - an original marriage certificate; or a certified copy of a public record of marriage. Row 2 Divorce/annulment Evidence a certified copy of the decree of divorce or annulment. Death of your spouse Evidence a certified copy of a death certificate, certified copy of the public record of death, or a certified copy of a coroner's certificate. Row 4 work stoppage or reduction Evidence 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. Row 5 Loss of Income Producing Property Evidence 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 you or your spouse's loss. Row 6 Loss of Pension Income Evidence Ay letter or statement from your pension fund administrator that explains the reduction or termination of your benefits. Row 7, Employer Settlement Payment Evidence Ay 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 M Ay G I information to make a decision about your income-related monthly adjustment amount, we will later check with the IRS to verify your report. • If you provide an estimate of your M Ay G I 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 M Ay G I 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. • We will use your estimate provided in Step 2 to make a decision about the amount of your income related monthly adjustment amounts the following year until: • IRS sends us your tax return information for the year used in Step 2; or • You provide a signed copy of your filed Federal income tax return or amended Federal income tax return with a different amoung; or •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 (T T Y 1-800-325-0778) to explain that you lived apart from your spouse. Do not use this form to report this change. This is the last field on the form. If you tab out of this field you will be at the beginning of the form | Text |
This field contains detailed instructions and evidence requirements for various life-changing events that may affect your Medicare Income-Related Monthly Adjustment Amount (IRMAA). It includes the types of documentation needed for events such as marriage, divorce, death of a spouse, work stoppage or reduction, loss of income-producing property, loss of pension income, and employer settlement payments. Additionally, it provides important information about how your Modified Adjusted Gross Income (MAGI) estimates are used and verified, and instructions for updating your information if changes occur. Fill only if 'Marriage' is 'Yes'
Depends on:
Marriage
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| Page 8 of 8. Below is a table with 2 columns and 7 rows. Column headers are Life Changing Event and Evidence. Row 1 Marriage Evidence - an original marriage certificate; or a certified copy of a public record of marriage. Row 2 Divorce/annulment Evidence a certified copy of the decree of divorce or annulment. Death of your spouse Evidence a certified copy of a death certificate, certified copy of the public record of death, or a certified copy of a coroner's certificate. Row 4 work stoppage or reduction Evidence 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. Row 5 Loss of Income Producing Property Evidence 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 you or your spouse's loss. Row 6 Loss of Pension Income Evidence Ay letter or statement from your pension fund administrator that explains the reduction or termination of your benefits. Row 7, Employer Settlement Payment Evidence Ay 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 M Ay G I information to make a decision about your income-related monthly adjustment amount, we will later check with the IRS to verify your report. • If you provide an estimate of your M Ay G I 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 M Ay G I 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. • We will use your estimate provided in Step 2 to make a decision about the amount of your income related monthly adjustment amounts the following year until: • IRS sends us your tax return information for the year used in Step 2; or • You provide a signed copy of your filed Federal income tax return or amended Federal income tax return with a different amoung; or •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 (T T Y 1-800-325-0778) to explain that you lived apart from your spouse. Do not use this form to report this change. This is the last field on the form. If you tab out of this field you will be at the beginning of the form | Text |
This field contains a table that outlines the types of evidence required for different life-changing events that may affect your Medicare Income-Related Monthly Adjustment Amount (IRMAA). It includes evidence for events such as marriage, divorce, death of a spouse, work stoppage or reduction, loss of income-producing property, loss of pension income, and employer settlement payment. Ensure you provide the appropriate documentation as specified for your particular life-changing event. Fill only if 'Marriage' is 'Yes'
Depends on:
Marriage
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| Tax Filing Status | ||
| Single | Checkbox |
Check this box if your tax filing status is Single for the current tax year. Fill only if 'Type of Life-Changing Event' is selected
Depends on:
Marriage, Divorce/Annulment, Death of Your Spouse, Work Stoppage, Work Reduction, Loss of Income-Producing Property, Loss of Pension Income, Employer Settlement Payment
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| Married, Filing Jointly | Checkbox |
Check this box if your tax filing status is Married, Filing Jointly for the current tax year. Fill only if 'Type of Life-Changing Event' is selected
Depends on:
Marriage, Divorce/Annulment, Death of Your Spouse, Work Stoppage, Work Reduction, Loss of Income-Producing Property, Loss of Pension Income, Employer Settlement Payment
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| Head of Household | Checkbox |
Check this box if your tax filing status is Head of Household for the current tax year. Fill only if 'Type of Life-Changing Event' is selected
Depends on:
Marriage, Divorce/Annulment, Death of Your Spouse, Work Stoppage, Work Reduction, Loss of Income-Producing Property, Loss of Pension Income, Employer Settlement Payment
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| Married, Filing Separately | Checkbox |
Check this box if your tax filing status is Married, Filing Separately for the current tax year. Fill only if 'Type of Life-Changing Event' is selected
Depends on:
Marriage, Divorce/Annulment, Death of Your Spouse, Work Stoppage, Work Reduction, Loss of Income-Producing Property, Loss of Pension Income, Employer Settlement Payment
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| Qualifying Widow(er) with Dependent Child | Checkbox |
Check this box if your tax filing status is Qualifying Widow(er) with Dependent Child for the current tax year. Fill only if 'Type of Life-Changing Event' is selected
Depends on:
Marriage, Divorce/Annulment, Death of Your Spouse, Work Stoppage, Work Reduction, Loss of Income-Producing Property, Loss of Pension Income, Employer Settlement Payment
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| Tax Filing Status and Income Level Selection | ||
| Single MAGI Range | Text |
Enter the modified adjusted gross income (MAGI) range corresponding to the Single, Head of household or Qualifying widow(er) filing status from your most recent tax return (for example, $106,000.01 - $133,000.00).
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| 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)* . [* 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.] And your M Ay G I was between One hundred thirty three dollars and one cent and One hundred sixty seven thousand dollars, your Part B monthly adjustment is One hundred eighty five dollars and zero cents and your prescription drug coverage monthly adjustment is thirty five dollars and thirty cents | Text |
Provide details about your Medicare Part B and prescription drug coverage premiums, including any income-related monthly adjustment amounts (IRMAA) based on your tax filing status and modified adjusted gross income (MAGI).
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| 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)* . [* 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.] And your M Ay G I was between one hundred sixty seven thousand dollars and one cent and two hundred thousand dollars, your Part B monthly adjustment is Two Hundred ninety five dollars and ninety cents and your prescription drug coverage monthly adjustment is fifty seven dollars and zero cents | Text |
Enter your tax filing status and Modified Adjusted Gross Income (MAGI) if you filed as Single, Head of household, Qualifying widow(er) with dependent child, or Married filing separately (and lived apart from your spouse) with a MAGI between $167,001 and $200,000. This will determine your Part B and prescription drug coverage monthly adjustments.
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| Single MAGI Bracket | Text |
Enter the modified adjusted gross income (MAGI) range of $200,000.01 to $499,999.99 for a single filer.
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| 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)* . [* 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.] And your M Ay G I was More than Four hundred ninety nine thousand dollars and ninety nine cents, your Part B monthly adjustment is four hundred forty three dollars and ninety cents and your prescription drug coverage monthly adjustment is eighty five dollars and eighty cents | Text |
Enter your tax filing status and Modified Adjusted Gross Income (MAGI) if you filed as Single, Head of household, Qualifying widow(er) with dependent child, or Married filing separately (and lived apart from your spouse) with a MAGI over $499,999. This will determine your Part B and prescription drug coverage monthly adjustments.
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| If you filed your taxes as Married filing jointly and your M Ay G I was between Two hundred twelve thousand dollars and one cent and Two hundred sixty six thousand dollars, your Part B monthly adjustment is seventy four dollars and ninety cents and your prescription drug coverage monthly adjustment is thirteen dollars and seventy cents | Text |
Enter your tax filing status and Modified Adjusted Gross Income (MAGI) if you filed as Married filing jointly with a MAGI between $212,001 and $266,000. This will determine your Part B and prescription drug coverage monthly adjustments.
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| If you filed your taxes as Married filing jointly and your M Ay G I was between two hundred sixty six thousand dollars and one cent and three hundred thirty four thousand dollars, your Part B monthly adjustment is One hundred eighty five dollars and zero cents and your prescription drug coverage monthly adjustment is thirty five dollars and thirty cents | Text |
Enter your tax filing status and Modified Adjusted Gross Income (MAGI) if you filed as Married filing jointly with a MAGI between $266,001 and $334,000. This will determine your Part B and prescription drug coverage monthly adjustments.
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| If you filed your taxes as Married filing jointly and your M Ay G I was between Three hundred thirty four thousand dollars and one cent and four hundred thousand dollars, your Part B monthly adjustment is Two hundred ninety five dollars and ninety cents and your prescription drug coverage monthly adjustment is fifty seven dollars and zero cents | Text |
Enter your tax filing status and Modified Adjusted Gross Income (MAGI) if you filed as Married filing jointly with a MAGI between $334,001 and $400,000. This will determine your Part B and prescription drug coverage monthly adjustments.
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| If you filed your taxes as Married filing jointly and your M Ay G I was between four hundred thousand dollars and one cent and seven hundred forty nine thousand nine hundred ninety nine dollars and ninety nine cents, your Part B monthly adjustment is four hundred six dollars and ninety cents and your prescription drug coverage monthly adjustment is seventy eight dollars and sixty cents | Number |
Enter your Modified Adjusted Gross Income (MAGI) if you filed taxes as 'Married filing jointly' and your income was between $400,000.01 and $749,999.99. This will determine your Part B and prescription drug coverage monthly adjustments.
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| If you filed your taxes as Married filing jointly and your M Ay G I was more than seven hundred fifty thousand dollars your Part B monthly adjustment is four hundred forty three and ninety cents and your prescription drug coverage monthly adjustment is Eighty five dollars and eighty cents | Number |
Enter your Modified Adjusted Gross Income (MAGI) if you filed taxes as 'Married filing jointly' and your income was more than $750,000. This will determine your Part B and prescription drug coverage monthly adjustments.
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| If you filed your taxes as Married filing separately (and you lived with your spouse during part of that tax year)* . [* 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.] And your M Ay G I was between one hundred six thousand dollars and one cent and three hundred ninety three thousand nine hundred ninety nine dollars and ninety nine cents, your Part B monthly adjustment is four hundred six dollars and ninety cents and your prescription drug coverage monthly adjustment is seventy eight dollars and sixty cents | Number |
Enter your Modified Adjusted Gross Income (MAGI) if you filed taxes as 'Married filing separately' and lived with your spouse during part of the tax year, with income between $106,000.01 and $393,999.99. This will determine your Part B and prescription drug coverage monthly adjustments.
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| If you filed your taxes as Married filing separately (and you lived with your spouse during part of that tax year)* . [* 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.] And your M Ay G I was more than three hundred ninety three thousand nine hundred ninety nine dollars and ninety nine cents. your Part B monthly adjustment is four hundred forty three dollars and ninety cents and your prescription drug coverage monthly adjustment is eighty five dollars and eighty cents | Number |
Enter your Modified Adjusted Gross Income (MAGI) if you filed taxes as 'Married filing separately' and lived with your spouse during part of the tax year, with income more than $393,999.99. This will determine your Part B and prescription drug coverage monthly adjustments.
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| Tax Year and Income | ||
| Tax Year | Text |
Please enter the last two digits of the tax year for which you are reporting income. Fill only if 'Type of Life-Changing Event' is selected
Depends on:
Marriage, Divorce/Annulment, Death of Your Spouse, Work Stoppage, Work Reduction, Loss of Income-Producing Property, Loss of Pension Income, Employer Settlement Payment
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| Adjusted Gross Income | Number |
Please provide your adjusted gross income (AGI) for the specified tax year, as used on line 11 of IRS form 1040. Fill only if 'Type of Life-Changing Event' is selected
Depends on:
Marriage, Divorce/Annulment, Death of Your Spouse, Work Stoppage, Work Reduction, Loss of Income-Producing Property, Loss of Pension Income, Employer Settlement Payment
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| Tax-Exempt Interest | Number |
Please provide your tax-exempt interest income for the specified tax year, as used on line 2a of IRS form 1040. Fill only if 'Type of Life-Changing Event' is selected
Depends on:
Marriage, Divorce/Annulment, Death of Your Spouse, Work Stoppage, Work Reduction, Loss of Income-Producing Property, Loss of Pension Income, Employer Settlement Payment
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