Form Il-1363 - Schedule A - Doctor'S Statement - 2001

Illinois Department of Revenue

2001 Schedule A

Doctor’s Statement

Attach to your Form IL-1363.

You may need to complete Schedule A if you are younger than 65 years of age on January 1, 2002, and

• you are the claimant, or

• you are the claimant’s spouse or qualified additional resident who is applying for Pharmaceutical

Assistance coverage.

Step 1:

Answer the following questions to determine if you should complete

this schedule.

1

Did you receive Social Security disability benefits in 2001?

Yes

No

2

Did you receive disability benefits from Railroad Retirement or Civil Service in 2001?

Yes

No

3

Did you receive disability benefits from the Veterans Administration in 2001?

Yes

No

4

Did you have a Class 2 disability card from the Illinois Secretary of State’s office in 2001?

Yes

No

If you answered “yes” to any of the questions 1 through 4, stop. Do not complete this schedule, instead

see the instructions for what you may need to attach.

Step 2:

Complete the following information about yourself.

Please print.

Complete a separate Schedule A for each person and attach it to the claimant’s Form IL-1363,

Application for Circuit Breaker and Pharmaceutical Assistance.

5

9

Social Security number

Birth date__ __/__ __/__ __ __ __

Month

Day

Year

6

10

Name_____________________________________________

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

First

MI

Last

Area code

7

11

Address_________________________________ Apt.______

Claimant’s Social Security number

(from Line 1 of Form IL-1363)

8

City_________________________ State____ ZIP ________

Step 3:

A doctor must complete the following information about the person

named on Line 6.

The patient must meet the total disability criteria established by the Social Security Administration. Social Security

Administration guidelines do not include alcoholism or drug abuse as a qualification for disability status.

12

Patient’s name____________________________________________________________________

First

MI

Last

13

Date patient became disabled __ __/__ __/__ __ __ __

Month

Day

Year

14

Was the patient able to work for a living after the above date? Yes

No

15

Has the disability lasted or is it expected to continue for 12 months or more? Yes

No

16

What is the nature of the disability?____________________________________________________

17

Doctor’s name__________________________________________________________________

18

Doctor’s signature and date________________________________

__ __/__ __/__ __ __ __

Month

Day

Year

19

Doctor’s Illinois registration number 3 6 - ___ ___ ___ ___ ___ ___

(This number is issued by the Illinois Department of Professional Regulation.)

20

Doctor’s phone (__ __ __) __ __ __ - __ __ __ __

Area code

Schedule A (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.

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

IL-492-3691

(R-12/01)