Low-Cost Drug Program Form For The Elderly Or Disabled - Maine Revenue Services - 2002

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020381000
2002
LOW-COST DRUG PROGRAM
Elderly or Disabled
for the
Do not use red ink
Use blue or black ink.
a. Are you now a Maine resident? ............................ a.
1. Your First Name
M.I.
b. Do you receive State Supplemental
Income? .................................................................... b.
Your Last Name
c. Do you receive full Medicaid benefits? ............... c.
d. Do you receive any federal disability payments,
Your Social Security Number
Your Date of Birth
(including social security disability)? ..................... d.
-
-
-
-
e. Are you disabled based on social security
standards? ............................................................... e.
Month
Day
Year
a. Is your spouse now a Maine resident? .................. a.
2. Spouse’s First Name
M.I.
b. Does your spouse receive State Supplemental
Income? .................................................................... b.
Spouse’s Last Name
c. Does your spouse receive full Medicaid
benefits? .................................................................. c.
Spouse’s Social Security Number
Spouse’s Date of Birth
d. Does your spouse receive any federal disability
-
-
-
-
payments, (including social security disability)? .... d.
e. Is your spouse disabled based on social
Month
Day
Year
If spouse died during 2001
Ù
security standards? ................................................. e.
or 2002, enter date of death:
____
______
__________
3. Mailing Address (include your apartment number)
4. City, Town or Post Office
State
Zip Code
Telephone Number
-
-
(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.
a. Does this dependent receive State Supplemental
Dependent’s First Name
Income? .................................................................... a.
b. Does this dependent receive full Medicaid
Dependent’s Last Name
benefits? .................................................................. b.
c. Does this dependent receive any federal disability
Dependent’s Social Security Number
Dependent’s Date of Birth
payments, (including social security disability)? .... c.
-
-
-
-
d. Is this dependent disabled based on social
security standards? ................................................. d.
Month
Day
Year
a. Does this dependent receive State Supplemental
Dependent’s First Name
Income? .................................................................... a.
b. Does this dependent receive full Medicaid
Dependent’s Last Name
benefits? .................................................................. b.
c. Does this dependent receive any federal disability
Dependent’s Social Security Number
Dependent’s Date of Birth
payments, (including social security disability)? .... c.
-
-
-
-
d. Is this dependent disabled based on social
security standards? ................................................. d.
Month
Day
Year
over
Printed under Approp. 010 18F 1384.01

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