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Forms: IRWE Request Form
This request should accompany wage reports made to the Social Security Administration if you are a beneficiary receiving a Social Security or SSI disability benefit, or Medicaid under the 1619(b) provisions. You should include receipts, and proof of wages or your self-employment tax returns.
This is a request that the items described below be deducted as Impairment Related Work Expenses when you consider the work activity I am reporting. The items listed below meet the following requirements:
- They are necessary for my work activity or self-employment
- They were paid by me, and not reimbursed by another source
- They were not deducted as a business expense; and
- They relate to an impairment being treated by a health-care provider
- For each expense, I will attach a receipt. I will be happy to provide additional documentation, if requested.
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