This notice is used by the FO per HI 03010.040C.4. when requesting evidence needed to process a subsidy application.
Social Security Administration
Medicare Prescription Drug Assistance
Office address: 343 West Road
Burbank, MD 21217
Office Hours: 9:00 a.m.– 4:00 p.m.
Mr. Frank Johnson
1111 Bird Rd. Telephone: (410) 366-7770
Randallstown, Md. 21133 Date: 11/05/04
Social Security Number:
This is a very important letter and could affect whether you get subsidy to pay for
your prescription drugs. Please read carefully. If there is anything you do not understand,
please get in touch with us right away.
What You Need To Do
We need more information to decide if you are eligible for this extra help. Therefore,
it is important that you do the following: (Only the checked box applies to you.)
X Mail or bring in the items (s) checked on page 2 along with this letter as soon
as possible. The office address is at the top of this letter.
Call the office and ask for _____________________ .
If we asked to talk to you, it is because we need to discuss ______________________________________.
If We Do Not Hear From You
We may deny your Application for Help with Medicare Prescription Drug Plan Costs if
you do not respond to this request or contact us by ________ to tell us why.
Things We Need
We need to see the items shown below. Even if you don't have all of the information,
we need to hear from you. We will help you get anything you do not have. We will return
the item(s) to you. If you call or come in, please have this letter with you.
Mortgage statement for property on Jones Road .
Court record for settlement of property on Jones Road.
If You Have Any questions
If you have any questions or need help, please call us at the telephone number at
the top of this letter and ask for _______________________.
Postage Paid Return Envelope