BASIC (05-05)

HI 03094.020 SSA-L825 - Subsidy Application Cover Notice

A. Purpose/Use

The Subsidy Application Cover Notice (SSA-L825) is sent out by the field office only when an applicant insists on a “wet signature” rather than using attestation. This notice is initially available only in DPS. See HI 03010.030 for completion instructions.

B. Sample Notice SSA-L825 – Subsidy Application Cover Notice

Social Security Administration

Medicare Prescription Drug Assistance

Important Information

Field Office Address

                                                                  Date: December 10, 2005

Social Security Number: 123-00-6789

JOHN Q. PUBLIC

123 MAIN ST

SPRINGFIELD OH 45501

On December 10, 2005, we talked with you about your eligibility for extra help with Medicare prescription drug plan costs. We filled out the enclosed, “Application for Help with Medicare Prescription Drug Plan Costs”, based on your statements. However, we cannot decide if you are eligible until you sign the application and give us more information.

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What You Need To Do

  • Answer any questions circled on the application

  • Correct any information that is wrong

  • Sign and date the application in the space called “Your Signature.” If your husband or wife is living with you, please have him or her sign in the space called “Your Spouse’s Signature”

  • Mail or bring us the application and the information requested below along with this letter. If you mail the application and information, please use the enclosed postage paid envelope

If We Do Not Hear From You

It is important that you sign the application and return it to us right away. Send it to us even if you do not have all the information. The sooner we get the signed application, the sooner we can decide if you are eligible for extra help with Medicare prescription drug plan costs. If we receive the signed application by February 8, 2006, we will use December 10, 2005, the date you contacted us, as the filing date.

What Will Happen

If you file an application, we will review the claim and make a decision. If you do not agree with what we decide, you will be able to appeal the decision.

If You Have Any Questions

For general questions about obtaining extra help for Medicare prescription drug plan costs, visit our website at www.socialsecurity.gov on the Internet. There you will also find the laws and regulations about the extra help.

For specific questions about your case, you may call 443-424-4423 and ask for Mary Jones. We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

                                                                                  Social Security

                                                                                  FO address

                                                                                  Baltimore, MD 21201

If you do call or visit an office, please have this l