Social Security Administration

Fill out Form SSA-44 online

Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event

Form SSA-44 asks Social Security to use a more recent tax year's income when it sets your income-related monthly adjustment amount (IRMAA) for Medicare Part B and prescription drug coverage. It is for people who got a notice that their premiums include an IRMAA and whose income went down because of a life-changing event, such as marriage, divorce, a spouse's death, or stopping or cutting back work. The form is optional: you can call Social Security to schedule an appointment at a local office instead.

Fill out Form SSA-44 Blank form from the SSA

The form opens in our PDF editor with its own fields ready to type into. You can fill it in without an account; downloading the filled PDF needs a free account. A free account gets 15 credits a day, enough for one form a day.

Edition: (12-2025)
Pages: 8
Fillable fields: 54
Checked against the SSA: November 8, 2026

GuruPDF is not affiliated with the Social Security Administration. This page explains the form in plain words; it is not legal or tax advice. Always check the official instructions before you file.

Who uses Form SSA-44

People with Medicare Part B or prescription drug coverage whose notice says their premiums include an IRMAA
People whose income went down after a marriage, a divorce or annulment, or the death of a spouse
People who stopped working or reduced their work hours, or whose spouse did
People whose income went down because they or their spouse lost income-producing property, had an employer's pension plan stopped, ended or reorganized, or received a settlement from an employer because of its bankruptcy or reorganization

Before you start

The IRMAA notice from Social Security, which tells you which tax year was used
Your full name and your own Social Security number as they appear on your Social Security card (it may differ from the number on your Medicare card)
The month and year of each life-changing event
Your actual or estimated adjusted gross income (Form 1040, line 11) and tax-exempt interest (Form 1040, line 2a) for the more recent year
Your signed copy of your tax return or an IRS transcript, if you have already filed for that year
Original documents or certified copies that prove the event, such as a marriage certificate, divorce decree, death certificate or a statement from your employer

How to fill out Form SSA-44

Name and Social Security number (page 1)
Print your full name and your own Social Security number as they appear on your Social Security card. Page 1 also shows the table Social Security used to set your IRMAA. If you do not have to pay an IRMAA, the form says not to fill it out.
Step 1: Type of life-changing event
Check each event that applies: Marriage, Divorce/Annulment, Death of Your Spouse, Work Stoppage, Work Reduction, Loss of Income-Producing Property, Loss of Pension Income or Employer Settlement Payment. Enter the date of each event as mm/yyyy. The table on page 5 explains when to use each category. The event must be in the same year as, or earlier than, the tax year you ask Social Security to use.
Step 2: Reductions in income that have already occurred
Enter the tax year (20__), your adjusted gross income (line 11 of Form 1040) and your tax-exempt interest (line 2a of Form 1040), then check one tax filing status for that year. The year must be more recent than the one shown in your letter. You can enter actual or estimated amounts. Page 6 explains how the year is chosen; call Social Security if you are not sure which year to enter.
Step 3: Anticipated reductions next year
Answer whether your modified adjusted gross income will be lower next year than in the Step 2 year. If No, skip to Step 4. If Yes, enter the year after the Step 2 year, your estimated adjusted gross income, your estimated tax-exempt interest and your expected filing status. If you leave Step 3 blank, Social Security uses your Step 2 figures for the next year too, unless one of the conditions under "Important Facts" on page 8 applies.
Step 4: Documentation
Provide evidence of your income and of the life-changing event. You can attach it, and Social Security mails your originals or certified copies back, or you can show them to an SSA employee. If you filed a return for the Step 2 year, include your signed copy or an IRS transcript. The table on page 8 lists the evidence for each event.
Step 5: Signature
Read the statements above the signature line, then sign. Enter your phone number, mailing address, apartment number, city, state and ZIP code so Social Security can contact you about your request.

After you fill it out

You send the completed form and your evidence to Social Security. Social Security's page says you can fax or mail the form and evidence to a Social Security office; use its office locator to find your local office and check where to send it. Social Security also has its own online service where you can fill out and submit the request after you sign in to your Social Security account, and you can make an appointment instead.

Signing: You must sign Step 5, and by signing you declare under penalty of perjury that the information is true and correct. The form does not say whether an electronic signature is accepted on a faxed or mailed copy, so follow Social Security's instructions on how to sign.

Watch out for

If you do not have to pay an IRMAA, the form says not to fill it out, even if you had a life-changing event.
Do not use this form to report that you filed as married filing separately but lived apart from your spouse all year. The form says to call Social Security instead.
If you give an estimate, Social Security checks it with the IRS later. If your estimate changes, contact Social Security to update its records, or it may have to make corrections later, including retroactive assessments or refunds.
If you want your IRMAA changed because you amended your tax return, Social Security says to call them. They need to see a copy of the amended return you filed and your acknowledgment receipt from the IRS.

Questions about Form SSA-44

Do I have to use Form SSA-44?

No. The instructions say you do not have to complete the form to ask Social Security to use a more recent tax year. You can call Social Security and ask for an appointment at a local office instead.

Can I use an estimate if I have not filed my tax return yet?

Yes. Steps 2 and 3 accept estimated amounts. Social Security will later ask for a signed copy of your tax return once you file it, and it checks your figures with the IRS.

Does my request also lower my spouse's IRMAA?

No. Social Security's operations manual says a reported life-changing event applies only to the person who reports it. If the event affects your spouse, your spouse must contact Social Security.

What evidence of the life-changing event do I need?

Social Security must see original documents or certified copies, such as a marriage certificate, a divorce decree, a death certificate, or a statement from your employer or pension administrator. The table on page 8 of the form lists the evidence for each event. If you do not have the listed document, ask a Social Security representative what else can be accepted.

Is this the same as appealing my IRMAA decision?

No. An appeal is a separate request for reconsideration. Social Security says you do not need to file an appeal if you are asking for a new decision because a life-changing event lowered your income.