Application Form For Illinois Cares Rx - Illinois Department On Aging 2010 Page 2
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1
2
3(STEP 2 continued…)
11
Is your spouse a
U.S. citizen or
qualified noncitizen? (See instructions.)
Your spouse may still qualify for Illinois Cares Rx Basic even if no box is checked above.
12
Illinois Cares Rx Benefits. Your spouse can choose help paying for prescriptions.
F
F
a
Does your spouse have Medicare? yes
no
f “no,” go to Line 13.)
(I
F
F
b Does your spouse have HIV/AIDS? yes
no
(See instructions for additional benefits.)
13
Monthly Rebate. Your spouse can choose to receive a $25 monthly rebate instead of help paying
for prescriptions.
a Does your spouse have private insurance that pays for prescription drugs; or does your spouse have Veterans
Administration (VA) benefits; or is your spouse enrolled in a Medicare Part D plan
that does not coordinate
F
F
with Illinois Cares Rx? yes
no
f “no,” go to Step 3.)
(I
F
F
b Does your spouse want a $25 monthly rebate instead of help paying for prescriptions? yes
no
Do not mark “yes” if your spouse is receiving prescriptions through a coordinating Illinois Cares Rx
Medicare Part D plan. If your spouse is enrolled in one of these plans, Illinois Cares Rx will help pay
for his or her prescriptions.
3
Additional Information required for Illinois Cares Rx Benefits or monthly rebate.
STEP
:
Failure to complete this section will delay the processing of your application
14
If you are married and living with your spouse, do you have savings, investments or real estate worth more
than $25,010? If you are not married or you do not live with your spouse, is the value more than $12,510?
Do NOT count the home you live in, vehicles, personal possessions, burial plots, irrevocable burial
contracts or back payments from Social Security or SSI.
F
F
yes
no
If you marked NO, you must complete Schedule C.
4
STEP
:
For
your Qualified Additional Resident’s (QAR) Illinois Cares Rx Benefit or
Monthly Rebate
(See instructions.)
A QAR must be at least 16 years of age to qualify. QAR’s between 16 and 64 years of age must attach a
copy of their Social Security award letter for 2010.
15
QAR’s Social Security number
16
QAR’s Name
___________________________________________________________________________
First
M I
Last
17
QAR’s birth date
(See instructions.)
Month
Day
Year
18
Is your QAR a
U.S. citizen or
qualified noncitizen? (See instructions.)
Your QAR may still qualify for Illinois Cares Rx Basic even if no box is checked above.
(Continued on next page.)
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