Illinois Medicaid Redetermination Medical Renewal Form Page 4
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5State of Illinois
Department of Healthcare and Family Services
Department of Human Services
991010101
Illinois Medicaid Redetermination
Case ID: 066066010011Y
6. Do you or anyone living with you pay any of these expenses? Check all that apply.
£
How much?
How often?
Spousal suppor or child support
£
How much?
How often?
Child care expenses
£
How much?
How often?
Employment expenses
£
How much?
How often?
Other:______________________________
Æ
Attach proof of all expenses paid in the last 30 days.
7. Do you or anyone living with you still own these resources (assets) with these values?
£
£
Cash and bank accounts................................... Total $ 1111.00
Is this correct?
Yes
No
£
£
Life insurance (cash value)................................. Total $ 2222.00
Is this correct?
Yes
No
£
£
Burial fund or trust fund..................................... Total $ 3333.00
Is this correct?
Yes
No
£
£
Car, truck or motor vehicle................................ Total $ 8888.00
Is this correct?
Yes
No
£
£
Other property or land....................................... Total $ 5555.00
Is this correct?
Yes
No
£
£
Mutual funds, stocks, bonds............................. Total $ 4444.00
Is this correct?
Yes
No
£
£
401(k), IRA or Keough accounts........................ Total $ 7777.00
Is this correct?
Yes
No
£
£
Other resources................................................ Total $ 6666.00
Is this correct?
Yes
No
Æ
If you checked no for any resources, write the correct values in the next section.
8. Do you or anyone living with you own other resources (assets)? Check all that apply.
£
Cash and bank accounts
What is the value?
$ ___________________________________
£
Life insurance (cash value)
What is the value?
$ ___________________________________
£
Burial fund or trust fund
What is the value?
$ ___________________________________
£
Car, truck or motor vehicle
What is the value?
$ ___________________________________
£
Other property or land
What is the value?
$ ___________________________________
£
What is the value?
$ ___________________________________
Mutual fund, stocks, bonds
£
What is the value?
$ ___________________________________
401(k), IRA or Keough accounts
£
What is the value?
$ ___________________________________
Other:__________________________
Æ
Attach proof showing who owns these resources and the current value.
You do not need to attach proof of the value of your vehicle or your home.
Page 3
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E-mail us at or send a fax to 1-866-661-7025.
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Redetermination Notice (Non-MAGI)
02/14 - NMG - EN - 1
Llame al 1-855-458-4945.
20440212.999990000100 - 991010101
26 - 74910
03-03-7
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