Blank SSA SSA-44 Template

STEP 1: Type of Life-Changing Event

Check any life-changing event and fill in the date(s) that the events occurred (mm/yyyy).

If you have had or anticipate having a life-changing event, you can report to us an income reduction that has already occurred or an income reduction that you anticipate occurring this or next year. Use Step 2 to report reductions that have already occurred, and Step 3 to report reductions you are anticipating occurring. Additional instructions available on page 6).

STEP 2: Reductions in Income that have Already Occurred

If your income has already been reduced by the life-changing event (see instructions on page 6), the amount of your adjusted gross income (AGI, as used on line 11 of IRS form 1040) and tax-exempt interest income (as used on line 2a of IRS form 1040), and your tax filing status.

STEP 3: Anticipated Reductions in Modified Adjusted Gross Income Next Year

Will your modified adjusted gross income be lower next year than the year in Step 2?

No - Skip to STEP 4

Yes - Complete the blocks below for next year

Privacy Act Statement

Collection and Use of Personal Information

Sections 1839(i) and 1860D-13(a) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on your income-related monthly adjustment amount (IRMAA).

We will use the information you provide to determine if you qualify for a reduction in or elimination of IRMAA. We may also share the information for the following purposes, called routine uses:

•To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration of its programs. We contemplate disclosing information under this routine use only in situations in which SSA may enter into a contractual or similar agreement with a third party to assist in accomplishing an agency function relating to this system of records; and

•To applicants, claimants, prospective applicants or claimants (other than the data subjects and their authorized representatives) to the extent necessary for the purpose of administering Medicare Part A, Part B, Medicare Advantage Part C, and Medicare Part D, including but not limited to pursuing Medicare Part B, Part C and Part D premium collection.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0321, Medicare Database File, as published in the Federal Register (FR) on July 25, 2006, at 71 FR 42159. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.

Paperwork Reduction Act Statement

This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. We estimate that it will take about 45 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating this burden estimate or any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

INSTRUCTIONS FOR COMPLETING FORM SSA-44

Medicare Income-Related Monthly Adjustment Amount

Life-Changing Event--Request for Use of More Recent Tax Year Information

You do not have to complete this form in order to ask that we use your information about your modified adjusted gross income for a more recent tax year. If you prefer, you may call

1-800-772-1213 and speak to a representative from 7 a.m. until 7 p.m. on business days to request an appointment at one of our field offices. If you are hearing-impaired, you may call our TTY number, 1-800-325-0778.

Identifying Information

Print your full name and your own Social Security Number as they appear on your Social Security card. Your Social Security Number may be different from the number on your Medicare card.

STEP 1

You should choose any life-changing event on the list. Fill in the date that the life-changing event occurred. The life-changing event date must be in the same year or an earlier year than the tax year you ask us to use to decide your income-related premium adjustment. For example, if we used your 2023 tax information to determine your income-related monthly adjustment amount for 2025, you can request that we use your 2024 tax information instead if you experienced a reduction in your income in 2024 due to a life-changing event that occurred in 2024 or an earlier year.

INSTRUCTIONS FOR COMPLETING FORM SSA-44

STEP 2

Supply information about the more recent year's modified adjusted gross income (MAGI). Note that this year must reflect a reduction in your income due to the life-changing event(s) you listed in Step 1. A change in your tax filing status due to the life-changing event might also reduce your income-related monthly adjustment amount. Your MAGI is your adjusted gross income as used on line 11 of IRS form 1040 plus your tax-exempt interest income as used on line 2a of IRS form 1040. We used your MAGI and your tax filing status to determine your income-related monthly adjustment amount.

Tax Year

•Fill in both empty spaces in the box that says “20_ _". The year you choose must be more recent than the year of the tax return information we used. The letter that we sent you tells you what tax year we used.

•Choose this year (the "premium year") - if your modified adjusted gross income is lower this year than last year. For example, if you request that we adjust your income-related premium for 2025, use your estimate of your 2025 MAGI if:

1.Your income was not reduced until 2025; or

2.Your income was reduced in 2024, but will be lower in 2025.

•Choose last year (the year before the "premium year," which is the year for which you want us to adjust your IRMAA) - if your MAGI is not lower this year than last year. For example, if you request that we adjust your 2025 income-related monthly adjustment amounts and your income was reduced in 2024 by a life-changing event AND will be no lower in 2025, use your tax information for 2024.

•Exception: If we used IRS information about your MAGI 3 years before the premium year, you may ask us to use information from 2 years before the premium year. For example, if we used your income tax return for 2022 to decide your 2025 IRMAA, you can ask us to use your 2023 information.

•If you have any questions about what year you should use, you should call SSA.

Adjusted Gross Income

•Fill in your actual or estimated adjusted gross income for the year you wrote in the “tax year” box. Adjusted gross income is the amount on line 11 of IRS form 1040. If you are providing an estimate, your estimate should be what you expect to enter on your tax return for that year.

Tax-exempt Interest Income

•Fill in your actual or estimated tax-exempt interest income for the tax year you wrote in the “tax year” box. Tax-exempt interest income is the amount reported on line 2a of IRS form 1040. If you are providing an estimate, your estimate should be what you expect to enter on your tax return for that year.

Filing Status

•Check the box in front of your actual or expected tax filing status for the year you wrote in the “tax year” box.

INSTRUCTIONS FOR COMPLETING FORM SSA-44

STEP 3

Complete this step only if you expect that your MAGI for next year will be even lower. We will record this information and use it next year to determine your Medicare income-related monthly adjustment amounts. If you do not complete Step 3, we will use the information from Step 2 next year to determine your income-related monthly adjustment amounts, unless one of the conditions described in “Important Facts” on page 8 occurs.

Tax Year

•Fill in both empty spaces in the box that says “20 _ _ ” with the year following the year you wrote in Step 2. For example, if you wrote "2025" in Step 2, then write "2026" in Step 3.

Adjusted Gross Income

•Fill in your estimated adjusted gross income for the year you wrote in the “tax year” box. Adjusted gross income is the amount you expect to enter on line 11 of IRS form 1040 when you file your tax return for that year.

Tax-exempt Interest Income

•Fill in your estimated tax-exempt interest income for the tax year you wrote in the “tax year” box. Tax-exempt interest income is the amount you expect to report on line 2a of IRS form 1040.

Filing Status

•Check the box in front of your expected tax filing status for the year you wrote in the “tax year” box.

STEP 4

Provide your required evidence of your MAGI and your life-changing event.

Modified Adjusted Gross Income Evidence

If you have filed your Federal Income tax return for the year you wrote in Step 2, then you must provide us with your signed copy of your tax return or a transcript from IRS. If you provided an estimate in Step 2, you must show us a signed copy of your tax return when you file your Federal income tax return for that year.

Life-Changing Event Evidence

We must see original documents or certified copies of evidence that the life-changing event occurred. Required evidence is described on the next page. In some cases, we may be able to accept another type of evidence. If you do not have a preferred document listed on the next page. Ask a Social Security representative to explain what documents can be accepted.

STEP 5

Read the information above the signature line, and sign the form. Fill in your phone number and current mailing address. It is very important that we have this information so that we can contact you if we have any questions about your request.

Important Facts

•When we use your estimated MAGI information to make a decision about your income- related monthly adjustment amount, we will later check with the IRS to verify your report.

•If you provide an estimate of your MAGI rather than a copy of your Federal tax return, we will ask you to provide a copy of your tax return when you file your taxes.

•If your estimate of your MAGI changes, or you amend your tax return for that reason, you will need to contact us to update our records. If you do not contact us, we may have to make corrections later including retroactive assessments or refunds.

•We will use your estimate provided in Step 2 to make a decision about the amount of your income-related monthly adjustment amounts the following year until:

•IRS sends us your tax return information for the year used in Step 2; or

•You provide a signed copy of your filed Federal Income tax return or amended Federal Income tax return with a different amount; or

•You provide an updated estimate.

•If we used information from IRS about a tax year when your filing status was Married filing separately, but you lived apart from your spouse at all times during that year, you should contact us at 1-800-772-1213 (TTY 1-800-325-0778) to explain that you lived apart from your spouse. Do not use this form to report this change.