Social Security
                  Administration
         Medicare
                  Prescription Drug Assistance
         Receipt of Application 
          
          
         Wilkes-Barre Data Operation Center
           PO Box 1020
         Wilkes-Barre, PA 18767-1020
                                                            
                   Date: November 5, 2005
         
           Social Security Number: 123-00-6789
          
         JOHN Q. PUBLIC
         123 MAIN ST
         SPRINGFIELD OH 45501
          
          
          
                                           This
               is a Receipt for Your Application for
                                  Help
               With Medicare Prescription Drug Plan Costs
          
          
          
          
         We received your Application for Help with Medicare Prescription Drug Plan Costs and
            will process it as quickly as possible. We will contact you if we need more information.