Tax And Rent Refund Application - Maine Revenue Services - 2001
ADVERTISEMENT
1
2*010370000*
Tax and Rent Refund Application
Maine
Low-Cost Drug Program Application/Renewal
Revenue Services
PO Box 9116
*010370000*
Augusta, Maine 04332-9116
BE SURE TO ANSWER “Yes” or “No” to each question for
Do not use red ink.
each household member:
YOUR REFUND OR DRUG CARD WILL
Use blue or black ink.
BE DELAYED IF YOUR APPLICATION IS NOT COMPLETE.
a. Are you now a Maine resident? ................................ a.
Yes
N o
Check one:
Male
Female
b. Do you receive State Supplemental Income? ............b.
Yes
N o
1. Your First Name
M.I.
c. Do you receive full Medicaid benefits? .................. c.
Yes
N o
d. Do you receive any federal disability payments
Your Last Name
(including social security disability)? .........................d.
Yes
N o
e. Are you disabled based on social security
standards? ....................................................................... e.
Yes
N o
Your Social Security Number
Your Date of Birth
f. Were you a Maine resident for all of 2000? ...........f.
Yes
N o
-
-
-
-
g. Did you have a home or apartment in Maine for
Month
Day
Year
all of 2000 and live in your home or apartment
If applicant named above died during
Ù
for at least 6 months of 2000? ................................... g.
Yes
N o
–
–
2000 or 2001, enter date of death:
____
______
__________
2. Spouse's First Name
M.I.
Check one:
Male
Female
a. Is your spouse now a Maine resident? .................... a.
Yes
N o
b. Does your spouse receive State Supplemental
Spouse's Last Name
Income? ............................................................................b.
Yes
N o
c. Does your spouse receive full Medicaid
Spouse's Social Security Number
Spouse's Date of Birth
benefits? .......................................................................... c.
Yes
N o
-
-
-
-
d. Does your spouse receive any federal disability
Month
Day
Year
payments (including social security disability)? .......d.
Yes
N o
If spouse died during
e. Is your spouse disabled based on social security
Ù
–
–
2000 or 2001, enter date of death:
____
______
__________
standards? ....................................................................... e.
Yes
N o
3. Mailing Address (include your apartment number)
4. City, Town or Post Office
State
Zip Code
Telephone Number
-
-
5. Dependents. How many dependents do you have?
(DO NOT INCLUDE YOU OR YOUR SPOUSE.)
List your dependents below. If you have more than 2 dependents, list them on a separate sheet of paper.
Check one:
Male
Female
a. Does this dependent receive State Supplemental
Dependent's First Name
Income? ............................................................................ a.
Yes
N o
b. Does this dependent receive full Medicaid
Dependent's Last Name
benefits? ..........................................................................b.
Yes
N o
c. Does this dependent receive any federal disability
Dependent's Social Security Number
Dependent's Date of Birth
payments (including social security disability)? ....... c.
Yes
N o
-
-
-
-
d. Is this dependent disabled based on social
security standards? .......................................................d.
Yes
N o
Month
Day
Year
Check one:
Male
Female
Dependent's First Name
a. Does this dependent receive State Supplemental
Income? ............................................................................ a.
Yes
N o
b. Does this dependent receive full Medicaid
Dependent's Last Name
benefits? ..........................................................................b.
Yes
N o
c. Does this dependent receive any federal disability
Dependent's Social Security Number
Dependent's Date of Birth
payments (including social security disability)? ....... c.
Yes
N o
-
-
-
-
d. Is this dependent disabled based on social
Month
Day
Year
security standards? .......................................................d.
Yes
N o
Turn page over and fill out other side
Printed under Approp. 010 18F 1384.01
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial