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020381100

a. Maine adjusted gross income (from your 2001 Maine income tax return) ................................... 6a. $

Note: If you have not filed a 2001 Maine income tax return, leave this line blank and

enter your household income on line 6b.

b. Additional income (from schedule below) ................................................................................. 6b. $

c. Add line a and line b ..................................................................................................................... 6c. $

d. Rollovers of IRA, pension or annuities and Property Tax Program Refunds included on line 6a. ... 6d. $

(Read instructions on page 4 before entering an amount on this line.)

e. Total (subtract line 6d from line 6c) ............................................................................................. 6e. $

7. COSTS FOR PRESCRIPTION DRUGS. Enter money you paid for prescription drugs

for all members of the household in 2001. (See instructions on page 4.) ......................................... 7. $

Column 1

Column 2

SCHEDULE OF ADDITIONAL INCOME

For those who filed a

For those who did not

(for line 6b above)

2001 Maine Income

file a 2001 Maine

Tax Return

Income Tax Return

Additional Annual Income (Write in yearly income amounts.)

a. Gross Salaries, Wages ................................................................. a.

a. $

b. Dividends, Interest - all sources .................................................. b.

b. $

c. Loss Add-Back (see instructions below) .................................. c. $

d. Social Security, Railroad Retirement, Pensions,

Annuities, Veterans Compensations ........................................... d. $

d. $

e. Cash Public Assistance, TANF ................................................... e. $

e. $

f. State Supplemental Income (This is not social

security income) ........................................................................ f. $

f. $

g. Any other Income...................................................................... g. $

g. $

h. Total (add lines a through g) ....................................................... h. $

h. $

(Enter total from line h, either Column 1 or Column 2, on line 6b above.)

Loss Add-Back (line c)

Write in the total amount of the losses as a positive number.

Social Security, Railroad Retirement, and Pensions (line d)

Cash Public Assistance (line e)

Any Other Income (line g).

Under penalties of perjury,

Signature of Applicant

Date

Signature of Preparer other than Applicant

Date

Office Use only:

Low-Cost Drug Program Form For The Elderly Or Disabled - Maine Revenue Services - 2002 Page 2

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