Schedule C Form Il-1363 - Pharmaceutical Benefits - 2006

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Illinois Department on Aging

2006 Schedule C

Pharmaceutical Benefits

Attach to the claimant’s Form IL-1363.

Unless 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.

Claimant’s Social

Claimant’s

Security number

Birth

date__ __/__ __/__ __ __ __

Month

Day

Year

Claimant’s

Name__________________________________________

Marital status (

only one box)

First

Last

1 Single, widow(er), or divorced

Address__________________________________ Apt.___________

2 Married and living together

3 Married, but not living together

City_______________________ State_____ ZIP_________________

Phone

(__ __ __) __ __ __ - __ __ __ __

Spouse’s Social

Spouse’s

Security number

Birth

date__ __/__ __/__ __ __ __

Month

Day

Year

Spouse’s

Name_____________________________________________

First

Last

Step 2:

Complete the following information about you and your spouse

(if married and living together).

Did you work in 2006 or 2007?

You: yes

Spouse (If living together): yes

List your expected wages before taxes in 2007. If none, place a zero in the space.

You ..........

Spouse (If living together) ..........

If self-employed, list your expected net earnings or losses in 2007. If none, place a zero in the space.

You ..........

Spouse (If living together) ..........

Have any of the amounts you listed on Lines 6 or 7 decreased in the last two years? yes

If you recently stopped working or plan to stop working, enter the month and year.

You:

__ __/__ __ __ __

Spouse (If living together):

__ __/__ __ __ __

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

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. ...................................................................................................................

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-12/06)

Failure to provide information could delay your grant and/or prescription coverage. This form has been approved by the Forms Management Center.

IL-402-1096

Go to Page 6 - Schedule C