Schedule C - Attach To Form Il-1363 - Pharmaceutical Benefits - 2009 Page 2

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List the total amount of the savings and resources owned by you or your spouse. Also include items that

either of you own with another person. If none, place a zero in the space.

Bank Accounts (checking, savings and certificates of deposit) ....................................

Stocks, bonds, savings bonds, mutual funds, individual retirement accounts

and similar investments ................................................................................................

Any other cash at home or elsewhere ..........................................................................

13 a

Do you own life insurance policies with a total face value greater than $1,500?

If “no” for both of you, go to Line 14.

You: yes

Spouse (If living together): yes

If “yes” for either of you, list the amount you would get by cashing in your life insurance

policies. ............................................................................................................................

This is not the face value of your policies. You may need to call your insurance company to help

answer this question.

Do you plan to use any of the savings or resources on Lines 12a, 12b, 12c, and 13b to pay for funeral and

burial expenses for yourself or your spouse?

You: yes

Spouse (If living together): yes

Other than your home and the property on which it is located, do you or your spouse own any real estate?

yes

List the monthly income for each item below. If none, place a zero in the space.

You

Spouse

a Social Security ..........................

per month

b Railroad Retirement .................

per month

c Veterans Administration ...........

per month

d Other pensions and annuities ...

per month

e Other income not listed above ..

per month

Have any of the amounts listed in Lines 16a, 16b, 16c, 16d, or 16e decreased in the last two years?

You: yes

Spouse (If living together): yes

You

Spouse

18a

Do you get Social Security benefits for a disability? .......................... yes

yes

Do you get Social Security benefits because you are blind? ......... yes

yes

If “yes” for either Lines 18a or 18b and you pay for special

transportation, personal attendant services, or adaptive

equipment to work, list how much you pay each month. ..............

Step 3: 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 and

the Social Security Administration permission to get records from anyone concerning information on this form. As permitted by law, and subject to resource

availability, I authorize the state of Illinois to apply on my behalf for any federal drug benefits I may be eligible to receive under the Medicare program.

_________________________________/___/___

__________________________ ____________

Claimant’s signature

Date

Preparer’s name (Please print or type.)

Phone number

_________________________________/___/___

Spouse’s signature (If living together)

Date

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Schedule C / IL-1363 (R-12/09)

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