Form SSA-44: Medicare Income-Related Monthly Adjustment Amount — Life-Changing Event
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Form SSA-44, Medicare Income-Related Monthly Adjustment Amount — Life-Changing Event (edition 12-2025), asks Social Security to lower or remove the income-related surcharge (IRMAA) on your Medicare Part B and Part D premiums when one of eight life-changing events — marriage, divorce or annulment, death of a spouse, work stoppage, work reduction, loss of income-producing property, loss of pension income or an employer settlement payment — has cut your income below the tax return SSA used, which for 2026 premiums is your 2024 return. You name the event and its date, report the more recent year's adjusted gross income and tax-exempt interest, attach evidence and sign. Submit it online through SSA's "Request to lower an IRMAA" page after signing in, or fax or mail it to your local Social Security office. With JustFill you upload the blank SSA-44 PDF, the AI maps each field, and the first clean completed PDF download is included at no charge.
Medicare bases the IRMAA surcharge on the tax return the IRS sends SSA, normally from two years earlier: 2026 premiums use your 2024 return (or 2023 if that was all the IRS had). If your MAGI is at or below $109,000 — $218,000 filing jointly — you pay no IRMAA, and the form itself says not to file it. If a qualifying life-changing event has since reduced your income, Form SSA-44 lets you ask SSA to use a more recent year instead: usually the premium year (2026) if your income is lower this year than last, otherwise last year (2025). You tick the event, enter the year, your adjusted gross income (Form 1040 line 11) and tax-exempt interest (line 2a) and your filing status; if the following year will be lower still you add that estimate in Step 3; then you attach evidence of both the event and the income and sign. JustFill lets you complete the SSA-44 online so the event, year and figures are legible before you upload it to SSA, fax or mail it, or bring it to an appointment.
The official Form SSA-44 PDF (edition 12-2025, 8 pages: the four-page form plus instructions and the evidence table) is free at ssa.gov/forms/ssa-44.pdf — the old ssa.gov/forms/ssa-44.html page no longer exists. Open the blank PDF in JustFill to type your life-changing event, tax year and income figures, download the completed form (the first clean completed download is included at no charge), sign it, and then either upload it with your evidence through SSA's "Request to lower an IRMAA" page at ssa.gov/medicare/lower-irmaa or fax or mail it to your local Social Security office.
Get the official Form SSA-44 PDF from SSA (Social Security Administration)What each section of Form SSA-44 asks for. JustFill’s AI will detect these fields automatically when you upload the PDF — review the breakdown below so you know what to enter.
Tick any of the eight events — marriage, divorce/annulment, death of your spouse, work stoppage, work reduction, loss of income-producing property, loss of pension income, employer settlement payment — and give the date(s) in mm/yyyy. The event must fall in or before the tax year you ask SSA to use.
The more recent tax year (this year or last year — it must be later than the return SSA used), your actual or estimated adjusted gross income (Form 1040 line 11), tax-exempt interest (line 2a) and your filing status for that year. AGI plus tax-exempt interest is the MAGI SSA compares with the table on the form.
Only if your MAGI for the year after Step 2 will be lower still: that year, your estimated AGI and tax-exempt interest, and your expected filing status. Otherwise tick "No" and skip to Step 4.
Step 4: evidence of the life-changing event (original documents or certified copies — a marriage or death certificate, divorce decree, employer letter or pay stubs, pension-fund letter, settlement letter) and of your MAGI (a signed copy of the return or an IRS transcript, or the signed return later if you gave an estimate). Step 5: your signature under penalty of perjury, phone number and current mailing address.
A single retiree receives a 2026 IRMAA notice based on her 2024 return, when she was still working full time with a MAGI of about $160,000. She retired at the end of June 2025, so her 2026 income will be around $87,000 — below the first IRMAA tier. She asks SSA to use 2026 instead of 2024 and submits the form online.
JANE M DOE · •••-••-••••
Your own SSN as on your Social Security card — it may differ from the number on your Medicare card.
☑ Work Stoppage · Date(s): 06/2025
Work Stoppage and Work Reduction are separate boxes; dates are mm/yyyy. The event must fall in the same year as, or earlier than, the tax year you ask SSA to use.
2026
SSA used her 2024 return for the 2026 premium. The instructions say to choose the premium year itself when income is lower this year than last — 2025 still had six months of salary, so 2026 is the year to report.
AGI $85,000.00 (estimate) · Tax-exempt interest $2,000.00 (estimate)
AGI is line 11 of Form 1040 and tax-exempt interest is line 2a; together they are the MAGI ($87,000) SSA compares with the table on the form. Estimates are allowed until the return is filed.
☑ Single
The status you expect to use on the 2026 return.
☑ No — skip to Step 4
Only complete Step 3 if 2027 MAGI will be lower still. Otherwise SSA reuses the Step 2 figures next year until the IRS sends the actual 2026 return.
Original signed letter from the former employer confirming the last day of work, 06/26/2025 · signed copy of the 2026 return to follow once filed
SSA needs evidence of the event — for a work stoppage an employer statement or pay stubs; without them your signed statement on the form is accepted — and of your MAGI: a signed return or IRS transcript once one exists.
Signed · (512) 555-01•• · 100 Sample St, Apt 4, Austin, TX 78701
Signed under penalty of perjury. SSA calls this number if it has questions and mails original documents back to this address. There is no date line in Step 5.
Uploaded with the evidence through "Request to lower an IRMAA" at ssa.gov/medicare/lower-irmaa after signing in
The alternatives are faxing or mailing the form and evidence to your local Social Security office, or an appointment where you show originals or certified copies.
These values are made up. They are here to show what belongs on each line, not to be copied — every name, number, and address on your own Form SSA-44 has to be your own.
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Official source: Form SSA-44 on SSA (Social Security Administration)’s website
Edition checked: Form SSA-44 (12-2025), OMB No. 0960-0784, 8 pages — "Discontinue Prior Editions". Verified against the official source on .
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