Illinois Medicaid Redetermination Medical Renewal Form Page 3
ADVERTISEMENT
1
2
3
4
54. Do you and everyone living with you still get this income from these sources?
£
£
Salary, wages, and tips for everyone ......................
Total per month: $ 1111.99
Is this correct?
Yes
No
(total before taxes are taken out)
£
£
Self-employment income for everyone ...................
Total per month: $ 2222.99
Is this correct?
Yes
No
(profit once business expenses are paid)
£
£
Unemployment for everyone................................... Total per month: $ 3333.99
Is this correct?
Yes
No
£
£
Social Security for everyone ................................... Total per month: $ 4444.99
Is this correct?
Yes
No
£
£
Supplemental Security Income (SSI) for everyone... Total per month: $ 9999.99
Is this correct?
Yes
No
£
£
Workers' Compensation benefits for everyone........ Total per month: $ 1199.99
Is this correct?
Yes
No
£
£
Veterans benefits for everyone................................ Total per month: $ 2299.99
Is this correct?
Yes
No
£
£
Pension or retirement income for everyone............. Total per month: $ 5555.99
Is this correct?
Yes
No
£
£
Spousal support or child support
Total per month: $ 6666.99
Is this correct?
Yes
No
received by everyone..............................................
£
£
Rental fees or royalties for everyone........................Total per month: $ 7777.99
Is this correct?
Yes
No
£
£
Other income for everyone .....................................Total per month: $ 3399.99
Is this correct?
Yes
No
Æ
If you checked no for any income, write the correct amount in the next section.
5. Do you or anyone living with you get other income? Check all that apply.
£
How much?
How often?
Salary, wages, and tips
£
How much?
How often?
Self-employment
£
How much?
How often?
Unemployment
£
How much?
How often?
Social Security
£
Supplemental Security Income (SSI)
How much?
How often?
£
How much?
How often?
Workers’ Compensation benefits
£
Veterans benefits
How much?
How often?
£
How much?
How often?
Pension or retirement income
£
How much?
How often?
Spousal support or child support
£
How much?
How often?
Inheritance or trust fund
£
How much?
How often?
Rental fess or royalties
£
Other:__________________________
How much?
How often?
Æ
Attach proof of the amount for any income received in the last 30 days.
Page 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business