Social Security
Administration
Medicare
Prescription Drug Assistance
Application
Development
Office address: 343 West Road
Burbank, MD 21217
Office Hours: 9:00 AM – 4:00 PM
Telephone: (410) 366-7770
Date: 11/05/05
Social Security Number: 123-00-6789
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
This is a very important letter and could affect whether you get extra help 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 call us immediately at the phone number shown at the top
of this letter about the item(s) we listed under “Things We Need.”
If you prefer, you may mail or bring in the requested items to the address shown at
the top of this letter. We will return to you any item(s) you submit.
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 November 20, 2005.
Things We Need
We need to know more about the item(s) shown below.
-
•
Mortgage statement for property on Jones Road.
-
•
Court record for settlement of property on Jones Road.
Even if you do not have all of the information, we need to hear from you. We will
help you get anything you do not have. If you call or come in, please have this letter
with you.
If You Have Any Questions
If you have any questions or need help, please call us at the telephone number shown
at the top of this letter and ask for Mr.
James Robinson.
Manager
Enclosure(s)
Envelope