Schedule C - Attach To Form Il-1363 - Pharmaceutical Benefits - 2007

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Illinois Department on Aging
2007 Schedule C
Pharmaceutical Benefits
Attach to the claimant’s Form IL-1363.
If you marked "no" on Line 38a or 38b of Form IL-1363, you must complete Schedule C if you or your spouse are eligible
for Medicare and want help paying for prescription drugs or the $25 monthly rebate available through Illinois Cares Rx.
Step 1: Tell us about yourself (claimant) and your spouse.
Please print.
1a
b
Claimant’s Social
Claimant’s
Security number
Birth date
__ __/__ __/__ __ __ __
Month
Day
Year
2a
Claimant’s Name
_________________________________________
e
Marital status (
only one box)
First
MI
Last
1 Single, widow(er), or divorced
b
Address
_________________________________ Apt.___________
2 Married and living together
3 Married, but not living together
c
City
___________________________ State____
ZIP
____________
d
Phone
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
3a
b
Spouse’s Social
Spouse’s
Security number
Birth date
__ __/__ __/__ __ __ __
Month
Day
Year
4
Spouse’s Name
__________________________________________
First
MI
Last
Step 2: Complete the following information about you and your spouse
(if married and living together).
5
Did you work in 2007 or 2008?
You: yes
no
Spouse (If living together): yes
no
6
List your expected wages before taxes in 2008. If none, place a zero in the space.
You:
Spouse (If living together):
7
If self-employed, list your expected net earnings or losses in 2008. If none, place a zero in the space.
You:
Spouse (If living together):
8
Have any of the amounts you listed on Lines 6 or 7 decreased in the last two years? yes
no
9
If you recently stopped working or plan to stop working, enter the month and year.
You:
___ ___ / ___ ___ ___ ___
Spouse (If living together):
___ ___ / ___ ___ ___ ___
10
How many relatives live with you and depend on you or your spouse for at least one-half of their
financial support? If none, place a zero in the space. Do not count yourself or your spouse. .................
11 a
Does anyone provide or help you or your spouse pay for your food, mortgage, rent, heat/gas,
electricity, water or property taxes? Do not count: food stamps, house repairs, help from
a housing agency (Section 8), an energy assistance program, Meals on Wheels, or help
with medical treatment and drugs.
yes
no
b
If “yes,” how much help do you get each month? If the amount changes from month
to month or you do not receive it every month, tell us the average monthly amount
for the past year. .............................................................................................................
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. Failure to provide information could delay your grant and/or prescription coverage.
IL-402-1096
Schedule C / IL-1363 (R-12/07)
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Go to Page 6 - Schedule C

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