T®mg'dak'Bak¥suM km μviZIsnßM®◊k'emDIXar Application For Medicare Savings Programs

sUm/anesck†Ixage®kamØ¥◊nhμt'ct' munnwgbMeBjT®mg'dak'Bak¥suMenH.

va/a®s‡yelI®◊k'cMNUlnigZnZannanarbs'/ñk, km μviZIsnßM®◊k'emDIXar (Medicare Savings Program, MSP) /acCYybg'´z¬buB √laPZanara"b'rg Medicare Part B

CUn/ñk◊n. s®mab'Blrdƒx¬H, MSP /acCYybg'´z¬buB √laPZanara"b'rgemDIXar (Medicare) nig´z¬d´T@eT\t Edlkm μviZIemDIXar minbg'Ø¥. ´z¬TaMgenHKWrYmmannUv´z¬bg'Camun, ´z¬bg'shZanara"b'rg, nig´z¬bg'rg.

/ñknwg®tUvEteq¬IytbeTAnwgsMNYrTaMg/s' munnwgeyIg/acdwgzaetIeyIg/acCYy/ñk◊n…min◊n. ebI/ñk®tUvkarØ¥eKCYybMeBjEpñkNamYy´nT®mg'enH, sUmTUrs‡BÊTak'TgeTAkariyal‡yesvashKmn— (Community Services Office, CSO) mUldƒanrbs'/ñk.

sUmsresrØ¥c∫as'@.

1. eQμaHx¬Án

eQμaHkN†alCa/kßrkat'

eQμaH®tkUl

2. /asydƒanrs'enA

®kug

rdƒ

elxsuIbkUd

3. /asydƒansMbu®t (®bsinebIxusKñaBI/asydƒanxagelI)

®kug

rdƒ

elxsuIbkUd

4. elxTUrs‡BÊ TUrs‡BÊsMxan' –

TUrs‡BÊbnÊab'bnßM –

5. etI/ñkmanbJakñ¨gkarniyay, kars†ab', …karsresrPasa/g'eK¬geT? ◊T¿ca±H eT

etI/ñk®tUvkar/ñkbkE®beT? ◊T¿ca±H eT

ebI®tUvkar, enaHeyIgnwgp†l'mñak'CUn/ñk. etI/ñkniyayPasa/ √I?

B¤t·manTUeTA sUmrayeQμaHsamIx¬Án nigeQμaHmnusßd´T@eT\tTaMg/s' EdlkMBugrs'enACamYy/ñk. sUme®bIeQμaH®sbc∫ab'.

eQμaH namx¬Án, namkN†alkat', nam®kkUl

TMnak'TMngeTAnwg/ñl Ex´z©qñaM kMeNIt dak'Bak¥suMCMnYy…? ◊T¿ca±H eT

elxsn†isuxsg m eTP

®bus … ®sI samIx¬Án

b†I…®bBnÛ

B¤t·mans†IBIk´®mra"b'rgevCÇsa®s† (eBT¥) sUmKUs®b/b'mYyEdl/nuvt†cMeBaH/ñk /t†elxemDIXar

manlk ≈Nsm∫t†iTTYl …kMBugTTYl – Medicare Part A samIx¬Án ◊T¿ca±H eT

b†I…®bBnÛ ◊T¿ca±H eT

/ñkd´T ◊T¿ca±H eT

sUmKUs®b/b'mYyEdl/nuvt†cMeBaH/ñk /t†elxemDIXar

manlk ≈Nsm∫t†iTTYl …kMBugTTYl – Medicare Part B samIx¬Án ◊T¿ca±H eT

b†I…®bBnÛ ◊T¿ca±H eT

/ñkd´T ◊T¿ca±H eT

HCA 13-691 CA (1/12) Cambodian

á¿eyIgámankarZanara"b'rgevCÇsa®s†d´TeT\t. ◊T¿ca±H eT ebIman, etIkarZanara"b'rgenaHeQμaH/ √I ehIyetInrNa/ñk®tUv◊mra"b'rgedaykicçsn¥aZanara"b'rgenH?

etI/ñkbg'´z¬buB √laPZanara"b'rgemDIXars®mab'km μviZI Medicare Part A … Part B enAkñ¨gry⁄eBl 3 Excuge®kayenHeT? ◊T¿ca±H eT ebIbg', sUm®◊b'eyIgzaetICaExNa

B¤t·mans†IBI®◊k'cMNUl

s®mab'mnusßmñak'@ Edl/ñk◊nbJçËlkñ¨gT®mg'dak'Bak¥suMenH Edlman®◊k'cMNUl, sUmraycuH®◊k'cMNUlenAxage®kam. sUmcuHcMnYn®◊k'cMNUlmun kat'´z¬katB √kicçepßg@ecj (dUcCa´z¬BnÛ …´z¬Zanara"b'rgCaedIm). ®◊k'cMNUlKWrYmman b"uEn†minkMNt'EtcMeBaH –

®◊k'Ex ®◊k's√‡yCIvkm μ ®◊k'TwkEt

®◊k'´z¬bnÊb'sñak'enA nig ´z¬/ahar¿´z¬QñÁl(pÊH)

®◊k'k´®mra"b'rg®kumhflun /ysμ‡yyan

®◊k'k´®mra"b'rgsn†isux sg m

k´®mra"b'rg/tItyuTÛCn

®◊k'/aharkicçobt Ωm ∏/tItb†I …®bB‡nÛ ®◊k'k´®mra"b'rgkar/t'kargar eZ√I

…®◊k'k´®mra"b'rgkmμkr ®◊k'CMnYy SSU/saZarN⁄

®◊k'esaZn¿®◊k'cUlnivt†n— ®◊k'PaKlaP¿®◊k'kar®◊k' ®◊k'epßg@

eQμaH nieyaCk …®bPB´n®◊k'cMNUl cMnYn®◊k'muneBlkat' ´z¬katB√kicçepßg@ etI◊nTTYljwkjab' b"uNa?

B¤t·mans†IBI®TB¥skmμ

A. sUmrayeQμaH®TB¥skm μTaMg/s'. ®TB¥skm μKWrYmmannUvKNnIZnaKar, b‡NsnßM®◊k' (certificates of deposit), sJÔab‡NkmçIEpñksnßM®◊k' (savings bonds), IRA,

sJÔab‡Nkm μsiTÛi nigsJÔab‡NkmçI, sg hZn (mutual funds), ®◊k'suTÛ, nig®TB¥epßgeT\te®kABIpÊH…rzyn†rbs'/ñk. ebIsinCaman, sUmcuHeQμaH´n®TB¥skm μTaMgenaHenAkñ¨gtaragxage®kamenH –

eQμaHrbs'mças'®TB¥ ®bePT¿elxKNnIrbs'®TB¥skmμenaH t´m¬bcç¨b∫nñ

B. etI/ñk …b†I…®bBnÛrbs'/ñkman …kMBugTijrzyn†…yanyn†d´T@eT\t (dUcCarzyn†®twk, TUk, pÊHrzyn†, m"UtU, rzyn†CuMruM nig¿…rzseN†ag) …eT? ◊T¿ca±H eT

ebIsinCaman, sUmcuHeQμaH´n®TB¥sTaMgenaHenAkñ¨gtaragxage®kamenH –

eQμaHrbs'mças'®TB¥ ®TB¥ qñaM m"ak¿m"UEdl etIrzyn†enH◊ne®bI®◊s' edIm∫ I

dwknaM/tiziCneTAkan'kEn¬g Binit¥EzTaMsuxPaB…? t´m¬ cMnYn®◊k' Edl enACMBak'eK enAeLIy

◊T¿ca±H eT

◊T¿ca±H eT

◊T¿ca±H eT

◊T¿ca±H eT

HCA 13-691 CA (1/12) Cambodian

HCA 13-691 CA (1/12) Cambodian

C. etI/ñk …b†I…®bBnÛrbs'/ñkmankicçsn¥aZanara"b'rgCIvit Edlmansac'®◊k'elIsBI $1,500 …eT? sUmcuHeQμaH´n kicçsn¥aZanara"b'rgkarbJç¨HsB …EpnkarbJç¨HsBnanapgEdr. ◊T¿ca±H eT

ebIsinCaman, sUmcuHeQμaH´nkarZanara"b'rgTaMgenaHenAkñ¨gtaragxage®kamenH – eQμaHrbs'mças'kicçsn¥a eQμaH®kumh flunZanara"b'rg¿elxkicçsn¥a Zanara"b'rg t´m¬cuHelIb‡N t´m¬Ca®◊k' etInrNaCa/ñkEdl◊nra"b'rg edaykicçsn¥aenH?

sUm/aneday®by‡tñ®bEyg munnwgcuHht Ωelxa áyl'za –

á®tUvEtraykarN—Calaylk ≈N—/kßr…tamTUrs‡BÊ ®◊b'TIPñak'gar…tMNagrbs'TIPñak'gar Ø¥◊n®CabCabnÊan'/MBIkarp¬as'b†Ërkñ¨gsΩanPaBrbs' á. karraykarN—yWt/acnwgbN†al'Ø¥karp†l'CMnYymin®twm®tUv.

sΩanPaBrbs'á®tUvsΩite®kamkarbJÇak'edayTIPñak'garenH …edayTIPñak'garrbs'rdƒ…shB‡nÛ.

edIm∫ITTYlCMnYy, enaHá®tUvEtp†l'P‡s†¨tag enAeBlNa®tUv◊nesñIsuM. TIPñak'gar…tMNagrbs'TIPñak'gar/acCYyEs√grkP‡s†¨tag …/acCYyTak' TgeTAmnusßNamñak'…TIPñak'garNamYy edIm∫IesñIsuMP‡s†¨tagØ¥á.

tamry⁄karesñIsuM nigkarTTYlCMnYyEzTaMsuxPaB, ásUm®bKl'siTÛiTaMg/s'rbs'áCUnrdƒva"suInetan edIm∫Icat'Ecgkarobt Ωm ∏esvaEzTaMsuxPaB nigTar®◊k'BIPñak'garTIbIs®mab'´z¬esvaEzTaMsuxPaBnana.

kar®bkas nigkarcuHht Ωelxa á◊n/an ehIy◊nyl'sB √B¤t·mankñ¨gT®mg'dak'Bak¥suMenH. ásUm®bkas, e®kameTasbJÔt†i´nkas∫zbMBan, za B¤t·manEdlá◊np†l'CUnkñ¨gT®mg'dak' Bak¥suMenHTaMgb"unμanKWsuTÛEtCaB¤t·manBit, ®twm®tUv, nigeBjelj eTAtamkaryl'dwgd°®Cale®CAbMputrbs'á. ht Ωelxarbs'/ñkdak'Bak¥suM kalbriecœT

ht Ωelxarbs'b†I…®bBnÛ kalbriecœT

ht Ωelxarbs'CnEdlCYy/ñkdak'Bak¥suM /gkar

kalbriecœT

kar/nuJÔatØ¥ebIkbeJçjB¤t·man

ásUm/nuJÔatØ¥TIPñak'garenH …tMNagrbs'TIPñak'garenH /acebIkbeJçjB¤t·man/MBIT®mg'dak'Bak¥suMkm μviZIsnßM®◊k'emDIXar (Medicare Savings Programs) rbs'á eTACnNamñak'EdlCYybMeBjT®mg'dak'Bak¥suMenH …eTAtMNagBI/g karrbs'CnenaH.

ht Ωelxarbs'/ñkdak'Bak¥suM kalbriecœT

B¤t·mans 쇮Kcit† eyIgesñIsuM/ñk Ø¥®◊b'eyIg/MBIsavtar´nCatisasn— …CatiBnÛ¨rbs'/ñkedays 쇮K/MBIcit†. B¤t·manenHnwgmin®tUveKe®bI edIm∫Ivinicœ‡yemIllk ≈Nsm∫t†TTYl CMnYyrbs'/ñkeT.

CmCatiEs∫ks CnCati/aemrikaMgLataMg CnCatiEs∫kexμA CnCati/aemrikaMgedImkMeNIt≤NÎan¿/aLas ˚a CnCatiev\tNam¿lav¿Exμr kulsm ı‡nÛ –

CnCati/asuIepßgeT\t …CnCatiekaH◊ "suIh√ik epßg@ –

sUmcuHhtΩelxa nigkalbriecœTenAelIT®mg'dak'Bak¥suMrbs'/ñk ehIyykvaeTACUnkariyal‡yesvashKmn— (Community Services Office, CSO) mUldƒanrbs'/ñkvij …epΔIvaeTAkan' – DSHS CSD Customer Service Center PO Box 11699 Tacoma, WA 98411-6699

karerIse/Ig®tUv◊nhamXat'CakMjitkñ¨g®Kb'km μviZI nigskm μPaBTaMg/s' Edl◊np†l'CUnedayTIPñak'garenH …edaytMNagrbs'TIPñak'garenH. KμanCn Namñak'Kb∫I®tUveKpat'ecjBIkmμviZI nigskm μPaBTaMgenH edayEp÷kelICatisasn—, BN·sm∫r, eKalCMen], CMen]neya◊y, sJÇatiedIm, sasna, ePT, …BikarPaBenaHeLIy.