Medicare Savings Programs Application/redetermination (Qmb, Slmb, Almb) Page 2
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6Title VI of the Civil Rights Act of 1964 allows us to ask for race and ethnic origin information. You do not have to
give it to us. The information helps to make sure that we are following the federal civil rights law. If you do not
want to give us this information, it will not affect your application.
Are you Hispanic or Latino?
Yes
No
What is your racial origin? (check all that apply)
White
Black or African Descent
Native American or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Please give us information about your citizenship:
If no, what is your
non-citizen status?
What is your
What are the
What is your
sponsor’s
Are you a U.S.
(refugee, entrant,
alien
What is your
date and place
citizen?
permanent
registration
country of
that you came
name? (if
(check one)
resident, etc.)
number?
origin?
into the country?
appropriate)
Yourself
Yes
No
Your
Spouse
Yes
No
Please give us information about your Income:
Please list all income that you and your spouse receive. Please list the amounts of income before any deductions
are made. Examples of income are Social Security, Supplemental Security Income (SSI), wages, pensions,
disability benefits, worker’s compensation, unemployment compensation, interest, dividends, rental property
income, alimony and child support.
Income for Yourself
Income for Your Spouse
Name and Address of Employer, if any:
Name and Address of Employer, if any:
Name of Pension Company:
Name of Pension Company:
How often do
How often do
Where does the
How much do
you receive it?
Where does the
How much do
you receive it?
money come
you receive?
(Weekly,
money come
you receive?
(Weekly,
from?
Monthly or
from?
Monthly or
Quarterly)
Quarterly)
Social Security
$
Social Security
$
SSI
$
SSI
$
Pension
$
Pension
$
Wages
$
Wages
$
Interest
$
Interest
$
Other
Other
(describe):
$
(describe):
$
Other
Other
(describe):
$
(describe):
$
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