Form Il-1363 - 2009 Schedule B Qualified Additional Residents - State Of Illinois printable pdf download

State of Illinois, Department on Aging

2009 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 2009 and in 2010 at the time you file your 2009 Form IL-1363; and

• for whom you, or you and your spouse, provided more than half of that person’s total financial support in 2009; and

• who is not filing a separate 2009 Form IL-1363.

Step 1: Tell us about your qualified additional residents.

Please print.

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Social Security number

Name

______________________________________________________________________________

First

Last

Birth date

Month

Day

Year

yes

Check “yes” if requesting Illinois Cares Rx drug coverage. ..............................................................

Attach proof of age (first-time filer). If the person listed in Line 2 is younger than 65 years of age

and the box in Line 4 is checked, attach proof of disability.

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Social Security number

Name

______________________________________________________________________________

First

Last

Birth date

Month

Day

Year

yes

Check “yes” if requesting Illinois Cares Rx drug coverage. ..............................................................

Attach proof of age (first-time filer). If the person listed in Line 6 is younger than 65 years of age

and the box in Line 8 is checked, attach proof of disability.

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

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 2009, and that these individuals lived with me in the same residence in 2009 and in 2010 at the

time I filed my 2009 Form IL-1363.

_________________________________ ___/___/___

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. As permitted by law, and subject to revocation, I authorize

disclosure of the following information to, by, and between the Illinois Department on Aging and the Illinois Department of Healthcare and Family

Services for the Circuit Breaker/Illinois Cares Rx Programs: (1) citizenship, identification, and HIV/AIDS status information maintained by the Illinois

Department of Public Health; (2) tax return information maintained by the Illinois Department of Revenue and the Internal Revenue Service; (3)

citizenship and identification information maintained by the Illinois Secretary of State; and (4) identification information for ride programs offered by

mass transit authorities, for the limited purposes of confirming my eligibility for applicable benefits and related outreach enrollment efforts through the

end of the appropriate audit period. If resource availability permits, I also 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. I assign to the state of Illinois my right to any benefits, including reimbursement,

under any private plan of assistance, public assistance program, insurance plan, or from any liable third party, for prescription drugs that I receive

through the Illinois Cares Rx program. I also agree that if I receive any such payments or other payments or benefits under the programs on this form

in error, or that I was not entitled to, I will repay them to the state of Illinois. I authorize release of medical and pharmaceutical records for audit and

verification purposes, and exchange of health care information between any drug utilization review service authorized by the state of Illinois and any

of my physicians and pharmacists to the extent necessary for the operation of a drug utilization review service.

________________________

_________________________

___/___/___

Signature of person named on Line 2

Date

Signature of person named on Line 6

Date

This form is authorized as outlined by the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act.

1 of 1, Schedule B: IL-1363 (R-12/09)

Disclosure of this information is REQUIRED. Failure to provide information could delay your grant and/or prescription coverage.

IL-402-1095