Form SSA-44 (electronic SSA-44 (electronic Medicare Part B Income-Related Premium -- Life-Changing

IRMAA Re-determination Data Collection Screens

Last Updated: 10/02/2006

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1	C	IRMAA INCOME RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) MENU IRSU M07A
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4	u
5	m
6	n	*SELECT THE DESIRED FUNCTION: _
7	*	1=MAIN MENU
8	o	2=QUERY MENU
9	n	3=CALCULATOR.
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11	*
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1	C	IRMAA INCOME RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) MAIN MENU IRMN M07B
2	0	FIELD OFFICE: ­SSS *UNIT: ______
3	l
4	u	*BENEFICIARY SSN: _________
5	m
6	n	*SELECT THE DESIRED OPTION: _ 1=ESTABLISH 2=UPDATE 3=QUERY.
7	*
8	o	*SELECT THE DESIRED FUNCTION: _
9	n	1=LIFE CHANGING EVENT 2=TAX INFORMATION 3=MANUAL IRMAA ADJUSTMENT.
10	e
11	*	IF FUNCTION 2 SELECTED (ESTABLISH ONLY) INPUT TAX YEAR (CCYY): ____
12	r	IF FUNCTION 3 SELECTED (ESTABLISH ONLY) INPUT PREMIUM YEAR (CCYY): ____
13	e
14	s	IF APPEAL DETERMINATION, SELECT LEVEL: _
15	e	1=RECONSIDERATION 2=ALJ 3=APPEALS COUNCIL 4=COURT CASE.
16	r
17	v	SELECT APPEAL DISPOSITION: _
18	e	1=FULLY FAVORABLE REVERSAL 3=DISMISSAL 5=WITHDRAWAL 7=REMAND
19	d	2=PARTIALLY FAVORABLE REVERSAL 4=AFFIRMATION 6=ABANDON.
20		DATE OF APPEAL DETERMINATION (MMDDCCYY): ________
21		REMARKS: ______________________________________________________________________
22		_______________________________________________________________________________
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1	C	IRMAA LIFE CHANGING EVENT IRLC M07C
2	0	SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS
3	l
4	u
5	m	*SELECT LIFE CHANGING EVENT: _
6	n	1=DEATH OF SPOUSE 5=WORK STOPPED
7	*	2=MARRIAGE/REMARRIAGE 6=PENSION INCOME LOSS
8	o	3=DIVORCE 7=INCOME LOSS FROM INCOME PRODUCING PROPERTY
9	n	4=WORK REDUCTION 8=NON-QUALIFYING EVENT.
10	e
11	*
12	r	*DATE OF LIFE CHANGING EVENT (MMCCYY): ______
13	e
14	s
15	e	*SELECT PROOF: _ 1=PROVEN 2=NOT PROVEN 3=PENDING.
16	r
17	v	REMARKS: ______________________________________________________________________
18	e	­­­­­­­_______________________________________________________________________________
19	d
20		DELETE THIS LIFE CHANGING EVENT OCCURRENCE (Y/N): _
21		THIS OCCURRENCE WILL BE DELETED – CONTINUE (Y/N): _
22		ENTER TAX YEAR (CCYY): ____
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1	C	IRMAA TAX INFORMATION IRMA M07D
2	0	SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS
3	l	TYPE: SSS TAX YEAR: SSSS AGI: SSSSSSSSSSSS- TAX EXEMPT INTEREST: SSSSSSSSSSSS
4	u
5	m	*BENEFICIARY REPORT DATE (MMDDCCYY): ________ *TAX YEAR (CCYY): ____
6	n	ADJUSTED GROSS INCOME: ____________- TAX EXEMPT INTEREST: ____________
7	*
8	o	SELECT SOURCE: _
9	n	1=TAX RETURN 3=ESTIMATED TAX DATA
10	e	2=AMENDED TAX RETURN 4=IRS TAX CORRECTION DATA.
11	*
12	r	*SELECT FILING STATUS: _
13	e	1=SINGLE 4=HEAD OF HOUSEHOLD
14	s	2=MARRIED FILING JOINTLY 5=QUALIFYING WIDOW/WIDOWER
15	e	3=MARRIED FILING SEPARATELY 6=MARRIED FILING SEPARATELY LIVING APART ALL YEAR.
16	r
17	v	*SELECT PROOF: _ 1=PROVEN 2=NOT PROVEN 3=PENDING. GOOD CAUSE (Y/N): _
18	e	REMARKS: ______________________________________________________________________
19	d	_______________________________________________________________________________
20		DELETE THIS TAX INFORMATION OCCURRENCE (Y/N): _
21		THIS OCCURRENCE WILL BE DELETED – CONTINUE (Y/N): _
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1	C	IRMAA ATTESTATION OF PENALTY OF PERJURY IRPP M07E
2	0	SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS
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5	m	I UNDERSTAND THAT BY SUBMITTING THIS EVIDENCE I AM DECLARING UNDER PENALTY
6	n	OF PERJURY THAT ALL THE INFORMATION PROVIDED IS TRUE AND CORRECT
7	*	TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANYONE WHO KNOWINGLY GIVES A
8	o	FALSE OR MISLEADING STATEMENT ABOUT A MATERIAL FACT OR CAUSES SOMEONE ELSE TO
9	n	DO SO, COMMITS A CRIME AND MAY BE SENT TO PRISON, OR MAY FACE OTHER PENALTIES,
10	e	OR BOTH.
11	*
12	r	*APPLICANT ATTESTS THAT ALL INFORMATION PROVIDED IS CORRECT (Y/N): _
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1	C	IRMAA MANUAL IRMAA ADJUSTMENT IRIA M07F
2	0	SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS
3	l
4	u	CURRENT IRMAA DATA
5	m	PREMIUM YEAR: SSSS TAX YEAR: SSSS FILING STATUS: SSSSSSSSSSSSSSSSSSSSSSSSS
6	n	AGI: SSSSSSSSSSSS- TAX EXEMPTINTEREST: SSSSSSSSSSSS IRMAA AMOUNT: SSSSSSSSSSSS
7	*
8	o	MANUAL IRMAA INPUT
9	n	*BENEFICIARY REPORT DATE (MMDDCCYY): ________ TAX YEAR (CCYY): ____
10	e	ADJUSTED GROSS INCOME: ____________- TAX EXEMPT INTEREST: ____________
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12	r	SELECT FILING STATUS: _
13	e	1=SINGLE 4=HEAD OF HOUSEHOLD
14	s	2=MARRIED FILING JOINTLY 5=QUALIFYING WIDOW/WIDOWER
15	e	3=MARRIED FILING SEPARATELY 6=MARRIED FILING SEPARATELY LIVING APART ALL YEAR.
16	r
17	v	PREMIUM YEAR: SSSS
18	e	SELECT IRMAA AMOUNT: _
19	d	0=NO IRMAA 2=LEVEL TWO (SSSS.SS) 4=LEVEL FOUR (SSSS.SS)
20		1=LEVEL ONE (SSSS.SS) 3=LEVEL THREE (SSSS.SS).
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1	C	IRMAA INCOME RELATED MONTHLY ADJUSTMENT AMOUNT RESULTS IRRE M07G
2	0	SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS
3	l
4	u	CURRENT IRMAA DATA
5	m	PREMIUM YEAR: SSSS TAX YEAR: SSSS FILING STATUS: SSSSSSSSSSSSSSSSSSSS
6	n	AGI: SSSSSSSSSSSS- TAX EXMP INTEREST: SSSSSSSSSSSS IRMAA AMOUNT: SSSSSSSSSSSS
7	*	RECALCULATED IRMAA DATA
8	o	PREMIUM YEAR: SSSS TAX YEAR: SSSS FILING STATUS: SSSSSSSSSSSSSSSSSSSS
9	n	AGI: SSSSSSSSSSSS- TAX EXMP INTEREST: SSSSSSSSSSSS IRMAA AMOUNT: SSSSSSSSSSSS
10	e
11		CURRENT IRMAA DATA
12	r	PREMIUM YEAR: SSSS TAX YEAR: SSSS FILING STATUS: SSSSSSSSSSSSSSSSSSSS
13	e	AGI: SSSSSSSSSSSS- TAX EXMP INTEREST: SSSSSSSSSSSS IRMAA AMOUNT: SSSSSSSSSSSS
14	s	RECALCULATED IRMAA DATA
15	e	PREMIUM YEAR: SSSS TAX YEAR: SSSS FILING STATUS: SSSSSSSSSSSSSSSSSSSS
16	r	AGI: SSSSSSSSSSSS- TAX EXMP INTEREST: SSSSSSSSSSSS IRMAA AMOUNT: SSSSSSSSSSSS
17	v
18	e	NEW DETERMINATION RESULTS: SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
19	d	*PROCESS IRMAA ADJUSTMENT (Y/N): _ *PROCESS TAX INFORMATION UPDATE (Y/N): _
20		*PROCESS IRMAA DISMISSAL (Y/N): _
21		*SELECTING “N” WILL CANCEL TRANSACTION - CONTINUE (Y/N): _
22		MORE (Y/N):_
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1	C	IRMAA PENDING LIFE CHANGING EVENTS IRLP M07H
2	0	SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS
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4	u
5	m	*SELECT DESIRED EVENT: __
6	n
7	*	01=REPORT DATE: ________ EVENT: _________________ DATE: ______ APPEAL: _____
8	o	02=REPORT DATE: ________ EVENT: _______________ DATE: ______ APPEAL: _____
9	n	03=REPORT DATE: ________ EVENT: _________ ______ DATE: ______ APPEAL: _____
10	e	04=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____
11	*	05=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____
12	r	06=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____
13	e	07=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____
14	s	08=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____
15	e	09=REPORT DATE: ________ EVENT: ______________ _ DATE: ______ APPEAL: _____
16	r	10=REPORT DATE: ________ EVENT: _____________ __ DATE: ______ APPEAL: _____
17	v	11=REPORT DATE: ________ EVENT: _____________ __ DATE: ______ APPEAL: _____
18	e	12=REPORT DATE: ________ EVENT: _____________ __ DATE: ______ APPEAL: _____
19	d	13=REPORT DATE: ________ EVENT: _____________ __ DATE: ______ APPEAL: _____
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1	C	IRMAA LIFE CHANGING EVENT QUERY HISTORY IRLQ M07I
2	0	SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS
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5	m	*SELECT DESIRED EVENT: __
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7	*	01=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____
8	o	02=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____
9	n	03=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____
10	e	04=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____
11	*	05=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____
12	r	06=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____
13	e	07=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____
14	s	08=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____
15	e	09=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____
16	r	10=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____
17	v	11=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____
18	e	12=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____
19	d	13=PROCESS: ________ STATUS: _ EVENT: __________ DATE: ______ APPEAL: _____
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22		MORE (Y/N): _
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1	C	IRMAA PENDING TAX INFORMATION IRTP M07J
2	0	SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS
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4	u
5	m	*SELECT DESIRED EVENT: __
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7	*	01=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____
8	o	02=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____
9	n	03=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____
10	e	04=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____
11	*	05=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____
12	r	06=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____
13	e	07=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____
14	s	08=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____
15	e	09=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____
16	r	10=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____
17	v	11=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____
18	e	12=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____
19	d	13=REPORT DATE: ________ TAX YEAR: ____ SOURCE: ______________ APPEAL: _____
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1	C	IRMAA TAX INFORMATION QUERY HISTORY IRTQ M07K
2	0	SSN: SSSSSSSSS NAME: SSSSSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSSSS DOB: SSSSSSSS
3	l
4	u
5	m	*SELECT DESIRED EVENT: __
6	n
7	*	01=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____
8	o	02=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____
9	n	03=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____
10	e	04=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____
11	*	05=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____
12	r	06=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____
13	e	07=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____
14	s	08=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____
15	e	09=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____
16	r	10=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____
17	v	11=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____
18	e	12=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____
19	d	13=PROCESS: ________ STATUS: _ YEAR: ____ SOURCE: ___________ APPEAL: _____
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22		MORE (Y/N): _
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1	C	IRMAA INCOME RELATED MONTHLY ADJUSTMENT AMOUNT CALCULATOR IRCA M070
2	0
3	l	BENEFICIARY TAX DATA
4	u
5	m	*SELECT FILING STATUS: _
6	n	1=SINGLE 4=HEAD OF HOUSEHOLD
7	*	2=MARRIED FILING JOINTLY 5=QUALIFYING WIDOW/WIDOWER
8	o	3=MARRIED FILING SEPARATELY 6=MARRIED FILING SEPARATELY LIVING APART ALL YEAR.
9	n
10	e	*PREMIUM YEAR (CCYY): ____
11	*
12	r	ADJUSTED GROSS INCOME: ____________- TAX EXEMPT INTEREST: ____________
13	e
14	s	CALCULATOR RESULTS
15	e
16	r	FILING STATUS: _ PREMIUM YEAR (CCYY): ____ MAGI: ____________-
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18	e	MODIFIED ADJUSTED GROSS INCOME RANGE ___________ TO ___________­
19	d
20		IRMAA LEVEL: _ IRMAA: _______
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