Form Il-1363 - Schedule B - Qualified Additional Residents - 2005

Illinois Department on Aging

2005 Schedule B

Qualified Additional Residents

Attach to claimant’s Form IL-1363.

Who is a qualified additional resident?

A qualified additional resident is an individual, other than your spouse,

• who lived with you in the same residence in 2005 and in 2006 at the time you file your 2005 Form IL-1363; and

• for whom you, or you and your spouse, provided more than half of that person’s total financial support in 2005; and

• who is not filing a separate 2005 Form IL-1363.

Qualified additional residents are not eligible for prescription drug coverage under the Illinois Cares Rx program.

Step 1: Tell us about your qualified additional residents.

Please print.

1

Social Security number

2

Name

_________________________________________________

First

MI

Last

3

Birth

date__ __/__ __/__ __ __ __

Month

Day

Year

4

Relationship to

claimant___________________________________

5

Social Security number

6

Name

_________________________________________________

First

MI

Last

7

Birth

date__ __/__ __/__ __ __ __

Month

Day

Year

8

Relationship to

claimant___________________________________

Step 2: Figure the total of your qualified additional residents.

9

9

Write the total number of persons you are reporting in Step 1.

Step 3: Claimant sign below.

Under penalties of perjury, I certify that the individuals listed in Step 1 are qualified additional residents for whom I, or my spouse and I, provided

more than half of their total financial support in 2005, and that these individuals lived with me in the same residence in 2005 and in 2006 at the time I file

my 2005 Form IL-1363.

10

11

______________________________/___/___

Claimant’s signature

Date

Claimant’s Social Security number

Step 4: Qualified additional residents sign below.

Under penalties of perjury, I state that I have examined this form and, to the best of my knowledge, it is true, correct, and complete. I give the state of Illinois

permission to get records from anyone concerning information on this form. I authorize the Illinois Department of Revenue to disclose information from any of

my tax returns for the limited purpose of confirming claimant’s eligibility for benefits.

12

______________________________/___/___

Signature of person named on Line 2

Date

13

______________________________/___/___

Signature of person named on Line 6

Date

Schedule B (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-12/05)

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

IL-402-1095