o enroll)" c Enrolled in Part B: Effective Date c Enrolled in Part D: Effective Date Reason for Medicare eligibility: O Over 65 Are you receiving Social Security Disability Insurance (SSDI)? ci YES O NO Start Date O Ineligible for Part B* O Not Enrolled in Part B (chose not to enroll)** c Ineligible for Part D* c Not Enrolled

chose not to enroll)' • Reason for Medicare eligibility: o Over 65 o Kidney Disease o Disabled o Disabled but actively at work Are you receiving Social Security Disability Insurance (SSDI)? o YES o NO Start Date Medicare — Spouse/Dependent Name: o Enrolled in Part A: Effective Date c Ineligible for Pail A' o Not Enrolled in

in Part D: Effective Date Reason for Medicare eligibility: Over 65 • Kidney Disease Disabled (2 Disabled but actively at work Are you receiving Social Security Disability Insurance (SSDI)? , . YES c: NO Start Date ___ If enrolled in Medicare, please attach a copy of your Medicare ID card. Ineligible for Part A' Not Enrolled

Federal health insurance program for virtually all persons age 65 and older, and permanently disabled persons under age 65, who qualify by receiving Social Security Disability Insurance. Mortgage-Backed Securities (MBSs) - Securities issued by financial institutions to investors with the payments of interest and principal backed by