Tea Party Revolution Starts Here: Form To Reject Medicare

Below is a handy-dandy form I've created that Tea Party adherents can use to reject Medicare, that odious Government-sponsored health care program. The next time the Tea Party hoses up traffic in Washington, DC, we residents, the true "taxation without representation" citizens, can bring hundreds of these forms for them to fill out. Hooray!

Name ________________ __ ____________________________

ADDRESS ________________________


DATE: _________________

Form TEAPARTY (10-2010) Destroy prior editions

Social Security Administration Important Information
You may also call 1-800-MEDICARE (TTY 1-877-486-2048) to renounce government-funded healthcare that is Medicare.

General Instructions for Rejecting Government-Funded Healthcare in the Form of Medicare

How To Complete This Application
Use BLACK INK only;
•Keep your numbers, letters and Xs inside the boxes; use only CAPITAL letters;
• Do not add any handwritten comments on the application;
• Do not use dollar signs when entering money amounts.

Completing Your Application
You may complete the application and send it to:
Social Security Administration Wilkes-Barre Data Operations Center P.O. Box 1020 Wilkes-Barre, PA 18767-9910

NOTE: To successfully submit this form, you must live in one of the 50 states or the District of Columbia.

Applicants Name
First _____________________
Middle Initial ________
Last _________________________
Suffix _____________

Social Security Number __________________
Applicant’s Date of Birth ____________________

By signing this form, I am affirming to the U.S. Government that I am rejecting Medicare coverage in all its forms. Medicare is an evil Government-sponsored health care program in which I will not participate. Withdraw my eligibility for the Medicare program immediately.

Signature ________________________

Print Name _______________________

Tel 800-325-0778 website www.SocialSecurity.gov

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