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, Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event has a moderate Form Complexity Index of 48/100 — Instafill’s AI completes it in under a minute.
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A completed Form SSA-44 example for a retiree requesting a Medicare premium adjustment due to a work stoppage.

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)
Categories: income forms, Medicare forms, SSA forms, L.A. Care forms
Created: February 25, 2026 05:40 PM
A completed Form SSA-44 example for a retiree requesting a Medicare premium adjustment due to a work stoppage.