2005 Schedule C - Pharmaceutical Benefits Form - Illinois Department On Aging
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1
2Illinois Department on Aging
2005 Schedule C
Pharmaceutical Benefits
Attach to the claimant’s Form IL-1363.
You must complete Schedule C if you, or your spouse, are Medicare-eligible and want help paying for your prescription drugs.
In order to be eligible for Illinois Cares Rx, you must also apply for “extra help” available under
Medicare Part D.
Step 1: Tell us about yourself (claimant).
Please print.
1
Social Security number
2
Name_____________________________________________
First
MI
Last
Step 2: Tell us about your spouse (husband or wife).
Please print.
3
Spouse’s Social Security number
4
Spouse’s
Name_____________________________________________
First
MI
Last
Step 3: Complete the following information about you and your spouse
(if married and living together).
5
Other than your home and the property on which it is located, do you own any real estate? Yes
No
6 a
Do you own life insurance policies with a total face value greater than $1,500? If you answered “No”
for both you and your spouse, go to Line 7.
You: Yes
No
Spouse (If living together): Yes
No
b
If the answer for either you or your spouse on Line 6a is “Yes,” how much money would
you get if you turned in your insurance policies for cash right now? Enter the amount....
This is not the face value of your policies. You may need to call your insurance company to help answer this question.
7
Do you plan to use any of your savings or resources to pay for funeral and burial expenses for yourself or
your spouse?
You: Yes
No
Spouse (If living together): Yes
No
8
Tell us how many relatives who live with you depend on you or your spouse for at least one-half of their
financial support. Do not count yourself or your spouse in this number.
0
1
2
3
4
5
6
7
8
9 or more
9
During the last two years, has your income from Social Security, Railroad Retirement or Veterans
Administration benefits, other pensions and annuities, or other income decreased?
You: Yes
No
Spouse (If living together): Yes
No
Schedule C (IL-1363)
This form is authorized as outlined by the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act. Disclosure of this information is REQUIRED.
(R-12/05)
Failure to provide information could delay your grant and prescription coverage. This form has been approved by the Forms Management Center.
IL-402-1096
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