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Extra Help Income and Resources (Assets) Worksheet
Please remember,
this worksheet is not an application for Extra Help. It is simply to help you prepare to apply for Extra Help.
:: Print Version
| 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 your 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 |
$ ___________ |
| Help from other people to pay for household expenses, such as food, mortgage or rent, heating fuel or gas, electricity, water and property taxes |
$ ___________ |
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Annual
Amount |
| Wages |
$ ___________ |
| Net earnings from self-employment |
$ ___________ |
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(Source: Social Security Administration: Understanding The Extra Help With Your Medicare Prescription Drug Plan publication 10508. Additional examples and links from Q1Group LLC)
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Last updated on: 09/01/2009
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Life Insurance plays an important role in your families financial stability.
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