Get This Form To Request A Reduction In Your Income-related Monthly Adjustment Amount - Dartmouth

Filling out the This Form To Request A Reduction In Your Income-related Monthly Adjustment Amount - Dartmouth can be a crucial step in reducing your Medicare costs after experiencing a life-changing event. This guide will provide clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete your request effectively.

1. Click ‘Get Form’ button to access the form and open it in your editor. Ensure you have a suitable environment to fill out the form online.
2. Start by entering your identifying information, including your full name and Social Security Number as they appear on your Social Security card.
3. In Step 1, check one life-changing event from the list and indicate the date the event occurred in the provided format (mm/dd/yyyy).
4. In Step 2, fill in the tax year during which your income was negatively impacted by the life-changing event. Provide your adjusted gross income and tax-exempt interest income for that tax year.
5. For Step 3, if you expect your modified adjusted gross income to be lower next year, complete the blocks with the estimated figures for adjusted gross income and tax-exempt interest for that year.
6. In Step 4, provide necessary documentation of your modified adjusted gross income and evidence of your life-changing event. Choose to either attach these documents or present them to a Social Security employee.
7. Finally, in Step 5, read the information carefully before signing the form. Ensure you include your phone number and current mailing address for any follow-up communication.

Complete your documents online to request the reduction in your income-related monthly adjustment amount today.