Extra Help Income and Resources (Assets) Worksheet
Please remember,this worksheet is not an application for Extra Help. It is simply to help you prepare to apply for Extra Help.
- Print Version
| Resources | Value |
| Bank accounts, including checking, savings and certificates of deposit | $ _________ |
| Stocks, bonds, savings bonds, mutual funds, individual retirement accounts (IRAs) or other investments | $ _________ |
| Cash at home or anywhere else | $ _________ |
| Any real estate other than your home | $ _________ |
Income |
Monthly Amount |
| Social Security benefits | $ _________ |
| Railroad Retirement benefits | $ _________ |
| Veterans benefits | $ _________ |
| Other pensions or annuities | $ _________ |
| Alimony | $ _________ |
| Net rental income | $ _________ |
| Workers’ compensation | $ _________ |
| Other income (private or State disability payments) | $ _________ |
| Annual Amount |
|
| Wages | $ _________ |
| Net earnings from self-employment | $ _________ |
Also see:
- 2026 Federal Poverty Level Guidelines (FPL): 2026/2027 LIS Qualifications and Benefits
- 2027 Low-Income Subsidy Benchmark Premium Amounts (includes 2026 - 2006 for comparison)
- What is the income limit for extra help?
- What does not count toward the income limit?
- What is the resource limit?
- What does not count as a resource?
- Income and Resources (Assets) Worksheet
- CMS Guide to LIS Consumer Mailings
- What will plans be like in 2027
(Source: Social Security Administration: Understanding The Extra Help With Your Medicare Prescription Drug Plan publication 10508, January 2011. Additional examples and links from this site)