This document provides instructions for requesting a reduction in Medicare premiums due to a life-changing event that has reduced income. It allows reporting of reduced income from either the current or previous tax year. Key details include choosing a qualifying life event, entering adjusted gross income and tax filing status for the selected year, and providing documentation of income and the event. Estimates for an even lower income in the following year can also be provided.
1042 S
101042 S
1096 Transmittal
1098
1098 C
1098 E
1098 Q
1098 T
1099 A
1099 B
1099 C
1099 CAP
1099 DIV
1099 G
1099 INT
1099 Laser Sets
1099 LTC
1099 MISC
1099 MISC Continuous
1099 OID
1099 PATR
1099 Q
1099 R
1099 S
1099 SA
1099-K
1099-R
3921
3922
5498
5498 ESA
5498 SA
ACA Forms
Envelopes
Laser 1099 Blank
Laser Cut Sheets
Miscellaneous Forms
Pressure Seal 11inch
Pressure Seal 14inch
Pressure Seal Stock
SS and OD Forms
W-2
W-2 Continuous
W-2 Laser Sets
W-2 Mailers
W-2G
W-3 Transmittal
W-9
W2 C
W2G
Presentation Folders
96 Transmittal
1098
1098 C
1098 E
1098 Q
1098 T
1099 A
1099 B
1099 C
1099 CAP
1099 DIV
1099 G
1099 INT
1099 Laser Sets
1099 LTC
1099 MISC
1099 MISC Continuous
1099 OID
1099 PATR
1099 Q
1099 R
1099 S
1099 SA
1099-K
1099-R
3921
3922
5498
5498 ESA
5498 SA
ACA Forms
Envelopes
Laser 1099 Blank
Laser Cut Sheets
Miscellaneous Forms
Pressure Seal 11inch
Pressure Seal 14inch
Pressure Seal Stock
Use this worksheet to complete the information we will use to complete your bankruptcy tax returns. Attach all slips (T4s etc.) and related tax information and remember to keep a copy of these for yourself.
For more information, visit us at:
http://www.djallen.ca
1042 S
101042 S
1096 Transmittal
1098
1098 C
1098 E
1098 Q
1098 T
1099 A
1099 B
1099 C
1099 CAP
1099 DIV
1099 G
1099 INT
1099 Laser Sets
1099 LTC
1099 MISC
1099 MISC Continuous
1099 OID
1099 PATR
1099 Q
1099 R
1099 S
1099 SA
1099-K
1099-R
3921
3922
5498
5498 ESA
5498 SA
ACA Forms
Envelopes
Laser 1099 Blank
Laser Cut Sheets
Miscellaneous Forms
Pressure Seal 11inch
Pressure Seal 14inch
Pressure Seal Stock
SS and OD Forms
W-2
W-2 Continuous
W-2 Laser Sets
W-2 Mailers
W-2G
W-3 Transmittal
W-9
W2 C
W2G
Presentation Folders
96 Transmittal
1098
1098 C
1098 E
1098 Q
1098 T
1099 A
1099 B
1099 C
1099 CAP
1099 DIV
1099 G
1099 INT
1099 Laser Sets
1099 LTC
1099 MISC
1099 MISC Continuous
1099 OID
1099 PATR
1099 Q
1099 R
1099 S
1099 SA
1099-K
1099-R
3921
3922
5498
5498 ESA
5498 SA
ACA Forms
Envelopes
Laser 1099 Blank
Laser Cut Sheets
Miscellaneous Forms
Pressure Seal 11inch
Pressure Seal 14inch
Pressure Seal Stock
Use this worksheet to complete the information we will use to complete your bankruptcy tax returns. Attach all slips (T4s etc.) and related tax information and remember to keep a copy of these for yourself.
For more information, visit us at:
http://www.djallen.ca
Knowing which tax documents you need and gathering them early is one of the top ways to save time and frustration when filing your US expat taxes from abroad.
Learn about the most common expat tax documents, where to find them, and how to navigate foreign documents during this webinar.
Being a freelancer is great. Self-employment is one of the most rewarding opportunities available. It's a foot-step for becoming a business owner.
It's not always easy. Finding clients, especially when starting out, can be the most difficult challenge. The tactics detailed in this presentation are designed to help your business when the future seems uncertain.
Knowing which tax documents you need and gathering them early is one of the top ways to save time and frustration when filing your US expat taxes from abroad.
Learn about the most common expat tax documents, where to find them, and how to navigate foreign documents during this webinar.
Being a freelancer is great. Self-employment is one of the most rewarding opportunities available. It's a foot-step for becoming a business owner.
It's not always easy. Finding clients, especially when starting out, can be the most difficult challenge. The tactics detailed in this presentation are designed to help your business when the future seems uncertain.
With all the planning and preparation that goes into a wedding, taxes may not be high on your summer wedding checklist. However, you should be aware of the tax issues that come along with marriage. Here are some basic tips to help with your planning:
Updating your status from single to married may bring about some unanticipated changes, including changes relating to your taxes. While wedding planners don’t typically use an IRS checklist, here are a few things to keep in mind when filing your first tax return as a married couple.
We acquire many of our customers through referrals from
satisfied clients. Beyond the benefit of being able to expand
our business, there are other reasons why we appreciate referrals.
When a client thinks enough of us to recommend
our services to a family member, friend, or co-worker, we
attain a higher quality clientele than those we acquire from
more random marketing efforts.
Form W-4 (2017)Purpose. Complete Form W-4 so that your emp.docxhanneloremccaffery
Form W-4 (2017)
Purpose. Complete Form W-4 so that your
employer can withhold the correct federal income
tax from your pay. Consider completing a new Form
W-4 each year and when your personal or financial
situation changes.
Exemption from withholding. If you are exempt,
complete only lines 1, 2, 3, 4, and 7 and sign the
form to validate it. Your exemption for 2017 expires
February 15, 2018. See Pub. 505, Tax Withholding
and Estimated Tax.
Note: If another person can claim you as a dependent
on his or her tax return, you can’t claim exemption
from withholding if your total income exceeds $1,050
and includes more than $350 of unearned income (for
example, interest and dividends).
Exceptions. An employee may be able to claim
exemption from withholding even if the employee is
a dependent, if the employee:
• Is age 65 or older,
• Is blind, or
• Will claim adjustments to income; tax credits; or
itemized deductions, on his or her tax return.
The exceptions don’t apply to supplemental wages
greater than $1,000,000.
Basic instructions. If you aren’t exempt, complete
the Personal Allowances Worksheet below. The
worksheets on page 2 further adjust your
withholding allowances based on itemized
deductions, certain credits, adjustments to income,
or two-earners/multiple jobs situations.
Complete all worksheets that apply. However, you
may claim fewer (or zero) allowances. For regular
wages, withholding must be based on allowances
you claimed and may not be a flat amount or
percentage of wages.
Head of household. Generally, you can claim head
of household filing status on your tax return only if
you are unmarried and pay more than 50% of the
costs of keeping up a home for yourself and your
dependent(s) or other qualifying individuals. See
Pub. 501, Exemptions, Standard Deduction, and
Filing Information, for information.
Tax credits. You can take projected tax credits into
account in figuring your allowable number of
withholding allowances. Credits for child or dependent
care expenses and the child tax credit may be claimed
using the Personal Allowances Worksheet below.
See Pub. 505 for information on converting your other
credits into withholding allowances.
Nonwage income. If you have a large amount of
nonwage income, such as interest or dividends,
consider making estimated tax payments using Form
1040-ES, Estimated Tax for Individuals. Otherwise,
you may owe additional tax. If you have pension or
annuity income, see Pub. 505 to find out if you should
adjust your withholding on Form W-4 or W-4P.
Two earners or multiple jobs. If you have a
working spouse or more than one job, figure the
total number of allowances you are entitled to claim
on all jobs using worksheets from only one Form
W-4. Your withholding usually will be most accurate
when all allowances are claimed on the Form W-4
for the highest paying job and zero allowances are
claimed on the others. See Pub. 505 for details.
Nonresident alien. ...
This worksheet is designed to be used by persons contemplating a divorce. It may
also be used by your attorney. Completing this form before your initial interview with your
attorney may save you valuable time and money
The CFPB is currently seeking public comment on several proposed amendments to its final rules issued in 2013, which went into effect in January 2014. The comment period is open through March 16, 2015, so mortgage servicers, or any interested parties, still have about a month to chime in on the proposed amendments.
By now, servicers are all familiar with the final CFPB Rules promulgated in 2013 that modified the impact of the Real Estate Settlement Procedures Act (RESPA) and the Truth in Lending Act (TILA). In November 2014, the Bureau proposed amendments to those Rules. Several proposed amendments are noteworthy to those in the mortgage servicing industry:
An expansion of "borrower" to include successors in interest to collateral property. Specifically, for the purposes of Regulation X, the Bureau is proposing to define "successor in interest" in § 1024.31 as "a member of any of the categories of successors in interest who acquired an ownership interest in the property securing a mortgage loan in a transfer protected by the Garn-St Germain Act." (See 12 U.S.C. § 1701j-3(d).) The expansion would include situations where the collateral property is transferred as a result of divorce. The effect of this would be that, for all intents and purposes of Regulation X, any successor in interest would now be considered a borrower.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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1. Form SSA-44 (11-2014)
Destroy Prior Editions
Social Security Administration
Medicare Income-Related Monthly Adjustment Amount -
Life-Changing Event
Form Approved
OMB No. 0960-0784
Page 1
If you had a major life-changing event and your income has gone down, you may use
this form to request a reduction in your income-related monthly adjustment amount.
See page 5 for detailed information and line-by-line instructions. If you prefer to
schedule an interview with your local Social Security office, call 1-800-772-1213
(TTY 1-800-325-0778).
Name Social Security Number
You may use this form if you received a notice that your monthly Medicare Part B (medical
insurance) or prescription drug coverage premiums include an income-related monthly
adjustment amount (IRMAA) and you experienced a life-changing event that may reduce your
IRMAA. To decide your IRMAA, we asked the Internal Revenue Service (IRS) about your
adjusted gross income plus certain tax-exempt income which we call "modified adjusted gross
income" or MAGI from the Federal income tax return you filed for tax year 2013. If that was not
available, we asked for your tax return information for 2012. We took this information and used
the table below to decide your income-related monthly adjustment amount.
The table below shows the income-related monthly adjustment amounts for Medicare
premiums based on your tax filing status and income. If your MAGI was lower than $85,000.01
(or lower than $170,000.01 if you filed your taxes with the filing status of married, filing jointly)
in your most recent filed tax return, you do not have to pay any income-related monthly
adjustment amount. If you do not have to pay an income-related monthly adjustment amount,
you should not fill out this form even if you experienced a life-changing event.
If you filed your taxes as: And your MAGI was:
Your Part B
monthly
adjustment is:
Your prescription
drug coverage
monthly
adjustment is:
-Single,
-Head of household,
-Qualifying widow(er) with dependent
child, or
-Married filing separately (and you did
not live with your spouse in tax year)*
$ 85,000.01 - $107,000.00
$107,000.01 - $160,000.00
$160,000.01 - $214,000.00
More than $214,000
$ 42.00
$104.90
$167.80
$230.80
$ 12.30
$ 31.80
$ 51.30
$ 70.80
-Married, filing jointly
$170,000.01 - $214,000.00
$214,000.01 - $320,000.00
$320,000.01 - $428,000.00
More than $428,000
$ 42.00
$104.90
$167.80
$230.80
$ 12.30
$ 31.80
$ 51.30
$ 70.80
-Married, filing separately (and you
lived with your spouse during part of
that tax year)*
$ 85,000.01 - $129,000.00
More than $129,000
$167.80
$230.80
$ 51.30
$ 70.80
* Let us know if your tax filing status for the tax year was Married, filing separately, but you lived apart
from your spouse at all times during that tax year.
2. Page 2
STEP 1: Type of Life-Changing Event
Check ONE life-changing event and fill in the date that the event occurred (mm/dd/yyyy). If
you had more than one life-changing event, please call Social Security at 1-800-772-1213
(TTY 1-800-325-0778).
Marriage
Divorce/Annulment
Death of Your Spouse
Work Stoppage
Work Reduction
Loss of Income-Producing Property
Loss of Pension Income
Employer Settlement Payment
Date of life-changing event:
mm/dd/yyyy
STEP 2: Reduction in Income
Fill in the tax year in which your income was reduced by the life-changing event (see
instructions on page 6), the amount of your adjusted gross income (AGI, as used on line 37 of
IRS form 1040) and tax-exempt interest income (as used on line 8b of IRS form 1040), and
your tax filing status.
Tax Year
2 0 __ __
Adjusted Gross Income
$ __ __ __ __ __ __ . __ __
Tax-Exempt Interest
$ __ __ __ __ __ __ . __ __
Tax Filing Status for this Tax Year (choose ONE ):
Single
Married, Filing Jointly
Head of Household
Married, Filing Separately
Qualifying Widow(er)
with Dependent Child
STEP 3: Modified Adjusted Gross Income
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
Tax Year
2 0 __ __
Estimated Adjusted Gross Income
$ __ __ __ __ __ __. __ __
Estimated Tax-Exempt Interest
$ __ __ __ __ __ __. __ __
Expected Tax Filing Status for this Tax Year (choose ONE ):
Single
Married, Filing Jointly
Head of Household
Married, Filing Separately
Qualifying Widow(er)
with Dependent Child
Form SSA-44 (11-2014)
3. Page 3
STEP 4: Documentation
Provide evidence of your modified adjusted gross income (MAGI) and your life-changing event.
You can either:
1. Attach the required evidence and we will mail your original documents or certified copies
back to you;
OR
2. Show your original documents or certified copies of evidence of your life-changing event
and modified adjusted gross income to an SSA employee.
Note: You must sign in Step 5 and attach all required evidence. Make sure that you provide
your current address and a phone number so that we can contact you if we have any
questions about your request.
STEP 5: Signature
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE SIGNING THIS
FORM.
I understand that the Social Security Administration (SSA) will check my statements with
records from the Internal Revenue Service to make sure the determination is correct.
I declare under penalty of perjury that I have examined the information on this form and
it is true and correct to the best of my knowledge.
I understand that signing this form does not constitute a request for SSA to use more
recent tax year information unless it is accompanied by:
• Evidence that I have had the life-changing event indicated on this form;
• A copy of my Federal tax return; or
• Other evidence of the more recent tax year's modified adjusted gross income.
Signature Phone Number
Mailing Address Apartment Number
City State ZIP Code
Form SSA-44 (11-2014)
4. Form SSA-44 (11-2014) Page 4
THE PRIVACY ACT
We are required by sections 1839(i) and 1860D-13 of the Social Security Act to ask you to give
us the information on this form. This information is needed to determine if you qualify for a
reduction in your monthly Medicare Part B and/or prescription drug coverage income-related
monthly adjustment amount (IRMAA). In order for us to determine if you qualify, we need to
evaluate information that you provide to us about your modified adjusted gross income.
Although the responses are voluntary, if you do not provide the requested information we will
not be able to consider a reduction in your IRMAA.
We rarely use the information you supply for any purpose other than for determining a potential
reduction in IRMAA. However, the law sometimes requires us to give out the facts on this form
without your consent. We may release this information to another Federal, State, or local
government agency to assist us in determining your eligibility for a reduction in your IRMAA, if
Federal law requires that we do so, or to do the research and audits needed to administer or
improve our efforts for the Medicare program.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state or local government
agencies. We will also compare the information you give us to your tax return records
maintained by the IRS. The law allows us to do this even if you do not agree to it. Information
from these matching programs can be used to establish or verify a person’s eligibility for
Federally funded or administered benefit programs and for repayment of payments or
delinquent debts under these programs.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Systems of Records Notice 60-0321 (Medicare Database File). The
Notice, additional information about this form, and any other information regarding our systems
and programs, are available on-line at www.socialsecurity.gov or at your local Social
Security office.
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 control number. We estimate that it will take about 45 minutes to read the instructions,
gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government
agencies in your telephone directory or you may call Social Security at 1-800-772-1213
(TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.
5. Form SSA-44 (11-2014) Page 5
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 only one life-changing event on the list. If you experienced more than one
life-changing event, please call your local Social Security office at 1-800-772-1213 (TTY
1-800-325-0778). 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 2013 tax information to
determine your income-related monthly adjustment amount for 2015, you can request that we
use your 2014 tax information instead if you experienced a reduction in your income in 2014
due to a life-changing event that occurred in 2014 or an earlier year.
Life-Changing Event Use this category if...
Marriage You entered into a legal marriage.
Divorce/Annulment
Your legal marriage ended, and you will not file a joint return
with your spouse for the year.
Death of Your Spouse Your spouse died.
Work Stoppage or Reduction
You or your spouse stopped working or reduced the hours
that you work.
Loss of Income-Producing
Property
You or your spouse experienced a loss of income-producing
property that was not at your direction (e.g., not due to the
sale or transfer of the property). This includes loss of real
property in a Presidentially or Gubernatorially-declared
disaster area, destruction of livestock or crops due to natural
disaster or disease, or loss of property due to arson, or loss
of investment property due to fraud or theft.
Loss of Pension Income
You or your spouse experienced a scheduled cessation,
termination, or reorganization of an employer's pension plan.
Employer Settlement Payment
You or your spouse receive a settlement from an employer
or former employer because of the employer's bankruptcy or
reorganization.
6. Form SSA-44 (11-2014) Page 6
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 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 37 of IRS form 1040 plus your tax-exempt interest income as used on
line 8b 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.
o 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 2015, use your estimate of your 2015 MAGI if:
1. Your income was not reduced until 2015; or
2. Your income was reduced in 2014, but will be lower in 2015.
o 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 2015 income-related monthly
adjustment amounts and your income was reduced in 2014 by a life-changing event
AND will be no lower in 2015, use your tax information for 2014.
o 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 2012 to
decide your 2015 IRMAA, you can ask us to use your 2013 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 37 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 8b 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.
7. Form SSA-44 (11-2014) Page 7
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 and will
reduce your IRMAA below what you told us in Step 2 using the table on page 1. 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 "2015" in Step 2, then write "2016" 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 37 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 8b 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.
8. Form SSA-44 (11-2014) Page 8
Life-Changing Event Evidence
Marriage
An original marriage certificate; or a certified copy of a public record of
marriage.
Divorce/Annulment A certified copy of the decree of divorce or annulment.
Death of Your Spouse
A certified copy of a death certificate, certified copy of the public record of
death, or a certified copy of a coroner’s certificate.
Work Stoppage or
Reduction
An original signed statement from your employer; copies of pay stubs;
original or certified documents that show a transfer of your business.
Note: In the absence of such proof, we will accept your signed statement,
under penalty of perjury, on this form, that you partially or fully stopped
working or accepted a job with reduced compensation.
Loss of Income-
Producing Property
An original copy of an insurance company adjuster’s statement of loss or a
letter from a State or Federal government about the uncompensated loss. If
the loss was due to investment fraud (theft), we also require proof of
conviction for the theft, such as a court document citing theft or fraud
relating to you or your spouse's loss.
Loss of Pension
Income
A letter or statement from your pension fund administrator that explains the
reduction or termination of your benefits.
Employer Settlement
Payment
A letter from the employer stating the settlement terms of the bankruptcy
court and how it affects you or your spouse.
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:
o IRS sends us your tax return information for the year used in Step 2; or
o You provide a signed copy of your filed Federal income tax return or amended Federal
income tax return with a different amount; or
o 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.