Social Security Administration's Printable Worksheet for
The Application For Help With Medicare Prescription Drug Costs

Resources Value
Bank accounts, including checking, savings and certificates of deposit $ 
Stocks, bonds, savings bonds, mutual funds, individual retirement accounts (IRAs) or other investments $ 
Cash at home or anywhere else $ 
Life insurance policies for you (and spouse, if married and living together) $ 

 

NOTE:Social Security needs to know how much money you would get if you cashed in your life insurance policies today. Check with your insurance company or agent to get the exact cash value. This probably will be less than the amount you are insured for.

 
Any real estate other than your home $ 
Income Monthly Amount
Social Security benefits $ 
Railroad Retirement benefits $ 
Veterans benefits $ 
Other pensions or annuities $ 
Alimony $ 
Net rental income $ 
Workers' compensation $ 
Other income (private or state disability payments) $ 

Help from other people to pay for household expenses, such as food, mortgage or rent, heating fuel or gas, electricity, water and property taxes

$ 
  Annual Amount
Wages $
Net earnings from self-employment $ 

Close this window