Form SSA-44, Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event Instructions
This form contains 54 fields organized into 20 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Applicant Identification (Name and SSN) | ||
| Applicant Name | Text |
Enter the applicant’s full legal name as it appears on Social Security records.
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| Applicant Social Security Number | Text |
Enter the applicant’s nine-digit Social Security number (SSN) without dashes.
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| General | ||
| Page 3 of 8. STEP 4: Documentation Provide evidence of your modified adjusted gross income (M Ay G I) 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; • Ay copy of my Federal tax return; or • Other evidence of the more recent tax year's modified adjusted gross income. Signature. Ay wet signature is required for this form. Form must be completed, printed and signed | Text | |
| Phone Number | Text | |
| Mailing Address | Text | |
| Apartment Number | Text | |
| City | Text | |
| State | Text | |
| ZIP Code | Text | |
| topmostSubform[0].P4_ReadOnly_FLD[0 | Text | |
| topmostSubform[0].P5_ReadOnly_FLD[0 | Text | |
| topmostSubform[0].P6_ReadOnly_FLD[0 | Text | |
| 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 "2024" in Step 2, then write "2025" 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 | |
| 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 | |
| topmostSubform[0].P7_ReadOnly_FLD[0 | Text | |
| Life-Changing Event Type and Date | ||
| Marriage | CheckBox |
Check this box if your life-changing event was a marriage.
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| Divorce/Annulment | CheckBox |
Check this box if your life-changing event was a divorce or annulment.
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| Death of Your Spouse | CheckBox |
Check this box if your life-changing event was the death of your spouse.
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| Work Stoppage | CheckBox |
Check this box if your life-changing event was a work stoppage.
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| Work Reduction | CheckBox |
Check this box if your life-changing event was a work reduction.
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| Loss of Income-Producing Property | CheckBox |
Check this box if your life-changing event was a loss of income-producing property.
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| Loss of Pension Income | CheckBox |
Check this box if your life-changing event was a loss of pension income.
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| Employer Settlement Payment | CheckBox |
Check this box if your life-changing event was an employer settlement payment.
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| Date(s) of Life-Changing Event | Date |
Enter the month and year when the selected life-changing event occurred in mm/yyyy format.
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| Married Filing Jointly MAGI >$750,000 Row | ||
| 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 nineteen dollars and thirty cents and your prescription drug coverage monthly adjustment is Eighty one dollars | Text | |
| Married Filing Jointly MAGI $206k–$258k Row | ||
| If you filed your taxes as Married filing jointly and your M Ay G I was between Two hundred six thousand dollars and one cent and Two hundred fifty eight thousand dollars, your Part B monthly adjustment is Sixty nine dollars and ninety cents and your prescription drug coverage monthly adjustment is Twelve dollars and ninety cents | Text | |
| Married Filing Jointly MAGI $258k–$322k Row | ||
| If you filed your taxes as Married filing jointly and your M Ay G I was between two hundred fifty eight thousand dollars and one cent and three hundred twenty two thousand dollars, your Part B monthly adjustment is One hundred seventy four dollars and seventy cents and your prescription drug coverage monthly adjustment is thirty three dollars and thirty cents | Text | |
| Married Filing Jointly MAGI $322k–$386k Row | ||
| MAGI Range | Text |
Enter the modified adjusted gross income range for married filing jointly filers whose MAGI falls between $322,000.01 and $386,000.00.
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| Married Filing Jointly MAGI $386k–$749,999 Row | ||
| If you filed your taxes as Married filing jointly and your M Ay G I was between three hundred eighty six thousand dollars and one cent and seven hundred ninety nine thousand nine hundred ninety nine dollars and ninety nine cents, your Part B monthly adjustment is three hundred eighty four dollars and thirty cents and your prescription drug coverage monthly adjustment is seventy four dollar and twenty cents | Text | |
| Married Filing Separately (Lived With Spouse) MAGI >$396,999 Row | ||
| Married Filing Separately (Lived With Spouse) MAGI more than $396,999.99 | Number |
Enter your modified adjusted gross income for the tax year if it was more than $396,999.99 and you filed as Married filing separately (and lived with your spouse during part of that year).
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| Married Filing Separately (Lived With Spouse) MAGI $103k–$396,999 Row | ||
| 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 three thousand dollars and one cent and three hundred ninety six thousand nine hundred ninety nine dollars and ninety nine cents, your Part B monthly adjustment is three hundred eighty four dollars and thirty cents and your prescription drug coverage monthly adjustment is seventy four dollars and twenty cents | Text | |
| Single / HOH / Qualifying Widow(er) MAGI >$499,999 Row | ||
| 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 nineteen dollars and thirty cents and your prescription drug coverage monthly adjustment is eighty one dollars | Text | |
| Single / HOH / Qualifying Widow(er) MAGI $103k–$129k Row | ||
| You may use this form if you received a notice that your monthly Medicare Part B (medical insurance) or prescription drug coverage premiums include an income-related monthly adjustment amount (IRMAA) and you experienced a life-changing event that may reduce your IRMAA. To decide your IRMAA, we asked the Internal Revenue Service (IRS) about your adjusted gross income plus certain tax-exempt income which we call "modified adjusted gross income" or MAGI from the Federal income tax return you filed for tax year 2022. If that was not available, we asked for your tax return information for 2021. 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 for Medicare premiums based on your tax filing status and income. If your M Ay G I was lower than One Hundred three thousand dollars and one cent (or lower than Two Hundred Six thousand dollars and one cent. 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 any 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 life changing 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)* . [* 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 MAGI was between One Hundred three thousand dollars and one cent and One Hundred Twenty Nine thousand dollars, your Part B monthly adjustment is Sixty Nine dollars and ninety cents and your prescription drug coverage monthly adjustment is twelve dollars and ninety cents | Text | |
| Single / HOH / Qualifying Widow(er) MAGI $129k–$161k Row | ||
| MAGI Range (Single/Head of Household/Qualifying Widow(er)) | Text |
Enter the modified adjusted gross income (MAGI) range for a single, head of household, or qualifying widow(er) filer, which should be $129,000.01 – $161,000.00.
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| Single / HOH / Qualifying Widow(er) MAGI $161k–$193k Row | ||
| Tax filing status (Single/Head of household/Qualifying Widow(er)) | Text |
Specify your tax filing status as Single, Head of household, or Qualifying widow(er) with a dependent child.
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| Single / HOH / Qualifying Widow(er) MAGI $193k–$499,999 Row | ||
| MAGI Range (Single/HOH/Qualifying Widow(er) $193,000.01–$499,999.99) | Text |
Enter the modified adjusted gross income range for single, head of household, or qualifying widow(er) filers whose MAGI falls between $193,000.01 and $499,999.99.
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| Step 2 Filing Status | ||
| Step 2 Filing Status: Single | CheckBox |
Check this box if your tax filing status for this tax year is Single.
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| Step 2 Filing Status: Married, Filing Jointly | CheckBox |
Check this box if your tax filing status for this tax year is Married, Filing Jointly.
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| Step 2 Filing Status: Head of Household | CheckBox |
Check this box if your tax filing status for this tax year is Head of Household.
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| Step 2 Filing Status: Married, Filing Separately | CheckBox |
Check this box if your tax filing status for this tax year is Married, Filing Separately.
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| Step 2 Filing Status: Qualifying Widow(er) with Dependent Child | CheckBox |
Check this box if your tax filing status for this tax year is Qualifying Widow(er) with Dependent Child.
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| Step 2 Income Already Occurred | ||
| Step 2 Tax Year | Text |
Enter the tax year (YYYY) for which your income reduction has already occurred.
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| Step 2 Adjusted Gross Income | Number |
Enter the amount of your adjusted gross income (AGI) from line 11 of IRS Form 1040 for the specified tax year.
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| Step 2 Tax-Exempt Interest | Number |
Enter the amount of your tax-exempt interest income from line 2a of IRS Form 1040 for the specified tax year.
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| Step 3 Anticipated Reduction Response | ||
| Step 3: No – Skip to STEP 4 | CheckBox |
Check this box if you do not expect your modified adjusted gross income to be lower next year than the year reported in Step 2.
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| Step 3: Yes – Complete the blocks below for next year | CheckBox |
Check this box if you expect your modified adjusted gross income to be lower next year than the year reported in Step 2.
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| Step 3 Expected Filing Status | ||
| Step 3 Expected Filing Status - Single | CheckBox |
Check this box if you expect to file as Single for the next tax year. Fill only if the 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Step 3: Yes – Complete the blocks below for next year
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| Step 3 Expected Filing Status - Married, Filing Jointly | CheckBox |
Check this box if you expect to file as Married, Filing Jointly for the next tax year. Fill only if the 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Step 3: Yes – Complete the blocks below for next year
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| Step 3 Expected Filing Status - Head of Household | CheckBox |
Check this box if you expect to file as Head of Household for the next tax year. Fill only if the 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Step 3: Yes – Complete the blocks below for next year
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| Step 3 Expected Filing Status - Married, Filing Separately | CheckBox |
Check this box if you expect to file as Married, Filing Separately for the next tax year. Fill only if the 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Step 3: Yes – Complete the blocks below for next year
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| Step 3 Expected Filing Status - Qualifying Widow(er) with Dependent Child | CheckBox |
Check this box if you expect to file as Qualifying Widow(er) with Dependent Child for the next tax year. Fill only if the 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Step 3: Yes – Complete the blocks below for next year
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| Step 3 Next Year Income | ||
| Step 3 Tax Year | Text |
Enter the four-digit tax year (YYYY) for which you are providing next year’s income estimates. Fill only if the 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Step 3: Yes – Complete the blocks below for next year
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| Step 3 Estimated Adjusted Gross Income | Number |
Enter your estimated adjusted gross income (AGI) for that tax year as you expect to report on line 11 of IRS Form 1040. Fill only if the 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Step 3: Yes – Complete the blocks below for next year
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| Step 3 Estimated Tax-Exempt Interest | Number |
Enter your estimated tax-exempt interest income for that tax year as you expect to report on line 2a of IRS Form 1040. Fill only if the 'Yes - Complete the blocks below for next year' is 'Yes'.
Depends on:
Step 3: Yes – Complete the blocks below for next year
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