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
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

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