Form Mi-1040cr-9 - Senior Citizen Prescription Drug Credit Claim 2001 - Michigan
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12001 MICHIGAN
2001
Senior Citizen Prescription Drug Credit Claim
MI-1040CR-9
Issued under P.A. 281 of 1967. Filing is voluntary.
You may apply for this credit only if you or your spouse is age 65 or older.
4
4
1.
2.
Your First Name, Middle Initial and Last Name
Your Social Security Number
4
3.
If a Joint Return, Spouse's First Name, Middle Initial and Last Name
Spouse's Social Security Number
4
4.
Home Address (No., Street, P.O. Box or Rural Route)
AGE. Check the box if you or your
spouse was age 65 or older as of
12/31/2001:
State
ZIP Code
City
You
Spouse
4
4
a.
b.
Limitations
To be eligible for this credit, you must be age 65 or older and your household income must be less than
$12,885 for single persons or $17,415 for married people. If you or your spouse lived in a licensed
health care facility, see instructions on back.
4
Licensed Health Care Facility Residents (see instructions for definition):
5.
Check the box if you or your spouse lived in a licensed health care facility
Spouse
You
4
4
for six consecutive months in 2001
a.
b.
2001 Household Income (see instructions)
Enter your household income on this line.
6.
This amount is on your 2001 MI-1040CR-7 (line 30), 2001 MI-1040CR
4
(line 29) or 2001 MI-1040CR-2 (line 29)
.00
6.
Your Credit Amount
7.
Amount you spent for your prescription drugs in 2001.
Include your drug costs only if you are age 65 or older and your
spouse's costs only if your spouse is age 65 or older
.00
4
7.
.00
Amount of line 7 paid by insurance, Medicaid or EPIC
8.
4
8.
Subtract line 8 from line 7
.00
9.
9.
Multiply your household income (line 6) by 5% (.05)
.00
10.
10.
.00
Your Credit. Subtract line 10 from line 9
11.
4
11.
Maximum credit is $600 for single persons, $1,200 for married people both age 65 or older.
The amount of your credit may be reduced by state law.
Checking
(1)
4
b. Account Type:
Direct
4
Deposit your refund directly
a. Routing Number
(2)
Savings
Deposit
into your bank account!
4
Complete a, b and c.
c. Account number
Deceased
If filer is deceased, enter
If spouse is deceased,
4
4
date of death.
enter date of death.
Taxpayers
I declare under penalty of perjury that the information in this return and attachments is true and
I declare under penalty of perjury that this return is based on all
complete to the best of my knowledge.
information of which I have any knowledge.
I authorize Treasury to discuss my return with my preparer.
Yes
No
Preparer's Name, Address, PTIN and/or FEIN
Filer's Signature
Date
Spouse's Signature
Date
Mail Your Claim To:
To be eligible you must file this
Michigan Department of Treasury
claim by June 3, 2002. Claims
Lansing, MI 48956
will be paid in August 2002.
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