Form SSA-44, Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event Instructions
This form contains 40 fields organized into 11 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Mailing Address | ||
| Mailing Address | Text |
Enter the street address for your mailing address.
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| Apartment Number | Text |
Enter your apartment, suite, unit, or building number.
|
| City | Text |
Enter the city for your mailing address.
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| State | Combobox |
Enter the state for your mailing address.
ND
WY
RI
KS
NE
LA
KY
SC
GA
IN
TX
UM
OR
PA
ID
AR
NC
NJ
IL
CA
UT
WI
VT
AK
ME
HI
MP
SD
IA
AS
CO
NY
NV
MD
GU
MN
TN
DC
OH
NH
OK
VI
WV
DE
WA
FL
MS
MT
MI
MO
AL
NM
VA
MA
AZ
CT
PR
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| ZIP Code | Text |
Enter the ZIP code for your mailing address.
|
| Name and Social Security Number | ||
| Full name | Text |
Enter your full legal name as shown on Social Security records (first, middle initial if any, and last name).
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| Social Security number | Text |
Enter your nine-digit Social Security Number exactly as issued, including dashes if you normally include them.
|
| Page 7 | ||
| P7_ReadOnly_FLD_p6_n1 | Text | |
| Phone Number | ||
| Phone Number | Text |
Please enter your contact phone number.
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| Step 1 Date(s) of life-changing event | ||
| Step 1 - Date(s) of life-changing event | Date |
Enter the date (month and year) when the life-changing event occurred or is expected to occur for the event you checked. Fill only if 'Step 1 - Marriage', 'Step 1 - Work Reduction', 'Step 1 - Divorce/Annulment', 'Step 1 - Loss of Income-Producing Property', 'Step 1 - Death of Your Spouse', 'Step 1 - Loss of Pension Income', 'Step 1 - Work Stoppage', 'Step 1 - Employer Settlement Payment' is 'Yes' (any).
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| Step 1 Event Types | ||
| Step 1 - Marriage | Radiobutton |
Check this box if you were married and are reporting that marriage as a life-changing event (enter the month/year it occurred).
|
| Step 1 - Work Reduction | Radiobutton |
Check this box if you experienced a reduction in work or work hours that reduced your income and you are reporting that change.
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| Step 1 - Divorce/Annulment | Radiobutton |
Check this box if you divorced or had your marriage annulled and are reporting that event (enter the month/year it occurred).
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| Step 1 - Loss of Income-Producing Property | Radiobutton |
Check this box if you lost property that produced income (for example rental or business property) and are reporting that loss.
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| Step 1 - Death of Your Spouse | Radiobutton |
Check this box if your spouse died and you are reporting that death as a life-changing event (enter the month/year it occurred).
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| Step 1 - Loss of Pension Income | Radiobutton |
Check this box if you lost pension income or your pension payments were reduced and you are reporting that change.
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| Step 1 - Work Stoppage | Radiobutton |
Check this box if you stopped working entirely (a work stoppage) and are reporting that event.
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| Step 1 - Employer Settlement Payment | Radiobutton |
Check this box if you received an employer settlement payment that affects your income and you are reporting that payment.
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| Step 2 Tax Filing Status | ||
| Step 2 - Single | Radiobutton |
Check this box if your tax filing status for the tax year shown is Single (select only one filing status). Fill only if 'Step 1 - Marriage', 'Step 1 - Work Reduction', 'Step 1 - Divorce/Annulment', 'Step 1 - Loss of Income-Producing Property', 'Step 1 - Death of Your Spouse', 'Step 1 - Loss of Pension Income', 'Step 1 - Work Stoppage', 'Step 1 - Employer Settlement Payment' is 'Yes' (any).
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| Step 2 - Qualifying Widow(er) with Dependent Child | Radiobutton |
Check this box if your tax filing status for the tax year shown is Qualifying Widow(er) with a Dependent Child (select only one filing status). Fill only if 'Step 1 - Marriage', 'Step 1 - Work Reduction', 'Step 1 - Divorce/Annulment', 'Step 1 - Loss of Income-Producing Property', 'Step 1 - Death of Your Spouse', 'Step 1 - Loss of Pension Income', 'Step 1 - Work Stoppage', 'Step 1 - Employer Settlement Payment' is 'Yes' (any).
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| Step 2 - Head of Household | Radiobutton |
Check this box if your tax filing status for the tax year shown is Head of Household (select only one filing status). Fill only if 'Step 1 - Marriage', 'Step 1 - Work Reduction', 'Step 1 - Divorce/Annulment', 'Step 1 - Loss of Income-Producing Property', 'Step 1 - Death of Your Spouse', 'Step 1 - Loss of Pension Income', 'Step 1 - Work Stoppage', 'Step 1 - Employer Settlement Payment' is 'Yes' (any).
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| Step 2 - Married, Filing Jointly | Radiobutton |
Check this box if your tax filing status for the tax year shown is Married, Filing Jointly (select only one filing status). Fill only if 'Step 1 - Marriage', 'Step 1 - Work Reduction', 'Step 1 - Divorce/Annulment', 'Step 1 - Loss of Income-Producing Property', 'Step 1 - Death of Your Spouse', 'Step 1 - Loss of Pension Income', 'Step 1 - Work Stoppage', 'Step 1 - Employer Settlement Payment' is 'Yes' (any).
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| Step 2 - Married, Filing Separately | Radiobutton |
Check this box if your tax filing status for the tax year shown is Married, Filing Separately (select only one filing status). Fill only if 'Step 1 - Marriage', 'Step 1 - Work Reduction', 'Step 1 - Divorce/Annulment', 'Step 1 - Loss of Income-Producing Property', 'Step 1 - Death of Your Spouse', 'Step 1 - Loss of Pension Income', 'Step 1 - Work Stoppage', 'Step 1 - Employer Settlement Payment' is 'Yes' (any).
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| Step 2 Tax Year Row (Reductions Already Occurred) | ||
| Step 2 Tax Year | Text |
Enter the four-digit tax year (YYYY) for which you are reporting the income reduction. Fill only if 'Step 1 - Marriage', 'Step 1 - Work Reduction', 'Step 1 - Divorce/Annulment', 'Step 1 - Loss of Income-Producing Property', 'Step 1 - Death of Your Spouse', 'Step 1 - Loss of Pension Income', 'Step 1 - Work Stoppage', 'Step 1 - Employer Settlement Payment' is 'Yes' (any).
|
| Step 2 Adjusted Gross Income (dollars) | Number |
Enter the adjusted gross income (AGI) amount for that tax year as reported on line 11 of IRS Form 1040. Fill only if 'Step 1 - Marriage', 'Step 1 - Work Reduction', 'Step 1 - Divorce/Annulment', 'Step 1 - Loss of Income-Producing Property', 'Step 1 - Death of Your Spouse', 'Step 1 - Loss of Pension Income', 'Step 1 - Work Stoppage', 'Step 1 - Employer Settlement Payment' is 'Yes' (any).
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| Step 2 Adjusted Gross Income (cents) | Text |
Enter the cents portion (two digits) of the adjusted gross income amount. Fill only if 'Step 1 - Marriage', 'Step 1 - Work Reduction', 'Step 1 - Divorce/Annulment', 'Step 1 - Loss of Income-Producing Property', 'Step 1 - Death of Your Spouse', 'Step 1 - Loss of Pension Income', 'Step 1 - Work Stoppage', 'Step 1 - Employer Settlement Payment' is 'Yes' (any).
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| Step 2 Tax-Exempt Interest (dollars) | Number |
Enter the tax-exempt interest amount for that tax year as reported on line 2a of IRS Form 1040. Fill only if 'Step 1 - Marriage', 'Step 1 - Work Reduction', 'Step 1 - Divorce/Annulment', 'Step 1 - Loss of Income-Producing Property', 'Step 1 - Death of Your Spouse', 'Step 1 - Loss of Pension Income', 'Step 1 - Work Stoppage', 'Step 1 - Employer Settlement Payment' is 'Yes' (any).
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| Step 2 Tax-Exempt Interest (cents) | Text |
Enter the cents portion (two digits) of the tax-exempt interest amount. Fill only if 'Step 1 - Marriage', 'Step 1 - Work Reduction', 'Step 1 - Divorce/Annulment', 'Step 1 - Loss of Income-Producing Property', 'Step 1 - Death of Your Spouse', 'Step 1 - Loss of Pension Income', 'Step 1 - Work Stoppage', 'Step 1 - Employer Settlement Payment' is 'Yes' (any).
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| Step 3 Anticipated Reduction Choice (Yes/No) | ||
| Step 3 - No | Radiobutton |
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 (skip to STEP 4).
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| Step 3 - Yes | Radiobutton |
Check this box if you DO expect your modified adjusted gross income to be lower next year than the year reported in Step 2 (and you will complete the estimated income blocks below).
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| Step 3 Estimated Income Row (Next Year) | ||
| Step 3 Tax Year (last digit) | Text |
Enter the last digit of the four-digit tax year for the next year you are estimating (the highlighted digit in the Tax Year box). Fill only if 'Step 3 - Yes' is 'Yes'.
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| Step 3 Estimated Adjusted Gross Income (dollars) | Number |
Enter your estimated adjusted gross income (AGI) for the next tax year. Fill only if 'Step 3 - Yes' is 'Yes'.
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| Step 3 Estimated AGI (cents) | Text |
Enter the cents portion (two digits) of your estimated adjusted gross income for the next tax year. Fill only if 'Step 3 - Yes' is 'Yes'.
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| Step 3 Estimated Tax-Exempt Interest (dollars) | Number |
Enter your estimated tax-exempt interest for the next tax year. Fill only if 'Step 3 - Yes' is 'Yes'.
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| Step 3 Estimated Tax-Exempt Interest (cents) | Text |
Enter the cents portion (two digits) of your estimated tax-exempt interest for the next tax year. Fill only if 'Step 3 - Yes' is 'Yes'.
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| Step 3 Expected Tax Filing Status | ||
| Step 3 Expected Tax Filing Status: Single | Radiobutton |
Check this box if you expect your tax filing status for the tax year estimated in Step 3 to be Single. Fill only if 'Step 3 - Yes' is 'Yes'.
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| Step 3 Expected Tax Filing Status: Head of Household | Radiobutton |
Check this box if you expect your tax filing status for the tax year estimated in Step 3 to be Head of Household. Fill only if 'Step 3 - Yes' is 'Yes'.
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| Step 3 Expected Tax Filing Status: Qualifying Widow(er) with Dependent Child | Radiobutton |
Check this box if you expect your tax filing status for the tax year estimated in Step 3 to be Qualifying Widow(er) with Dependent Child. Fill only if 'Step 3 - Yes' is 'Yes'.
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| Step 3 Expected Tax Filing Status: Married, Filing Jointly | Radiobutton |
Check this box if you expect your tax filing status for the tax year estimated in Step 3 to be Married, Filing Jointly. Fill only if 'Step 3 - Yes' is 'Yes'.
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| Step 3 Expected Tax Filing Status: Married, Filing Separately | Radiobutton |
Check this box if you expect your tax filing status for the tax year estimated in Step 3 to be Married, Filing Separately. Fill only if 'Step 3 - Yes' is 'Yes'.
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