Form SSA-44, Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event Completed Form Examples and Samples
Find clear, filled-out examples of Form SSA-44, the Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event form. Our samples cover common scenarios like retirement and work stoppage, helping you correctly report your new income and potentially lower your Medicare Part B and Part D premiums.
Form SSA-44 Example – Retirement/Work Stoppage
How this form was filled:
This sample shows how a recent retiree, Jane Smith, completes Form SSA-44 after her work stoppage. The form specifies 'Work Stoppage' as the Life-Changing Event, reports the higher income from tax year 2024 that triggered the IRMAA, and provides lower estimated income for 2025 and 2026 to request a recalculation of her Medicare premiums.
Information used to fill out the document:
- Filer's Name: Jane A. Smith
- Filer's Social Security Number: XXX-XX-1234
- Spouse's Name: John B. Smith
- Spouse's Social Security Number: XXX-XX-5678
- Phone Number: (555) 123-4567
- Address: 456 Oak Avenue, Anytown, USA 12345
- Life-Changing Event (LCE): Work Stoppage
- Date of LCE: 06/30/2025
- Tax Year for Original IRMAA: 2024
- 2024 Modified Adjusted Gross Income (MAGI): $220,000
- 2024 Tax Filing Status: Married Filing Jointly
- 2025 Estimated MAGI: $120,000
- 2025 Tax Filing Status: Married Filing Jointly
- 2026 Estimated MAGI: $95,000
- 2026 Tax Filing Status: Married Filing Jointly
- Evidence Provided: Signed statement from employer confirming retirement.
- Signature: Jane A. Smith
- Date Signed: 01/15/2026
What this filled form sample shows:
- Clearly identifies the Life-Changing Event (LCE) as 'Work Stoppage' in Step 1.
- Provides the original income information from the correct tax year (2024) used for the IRMAA calculation.
- Includes reduced estimated income figures for the year of the event (2025) and the following year (2026).
- Indicates the type of supporting documentation submitted with the form.
Form specifications and details:
| Form Name: | Form SSA-44 |
| Form Title: | Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event |
| Use Case: | Retiree requesting an IRMAA redetermination due to a work stoppage event. |
| Filing Agency: | Social Security Administration (SSA) |
Created: February 25, 2026 05:40 PM
