Line-By-Line Instructions For Schedule C (Form Il-1363)

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Line-by-line instructions for Schedule C
Complete this Schedule if you or your spouse are
6a
Mark “yes” if you own life insurance policies
Medicare-eligible and want help paying for drugs through
with a total face value greater than $1,500. (You
the Illinois Cares Rx program.
may need to call your insurance company to
help answer this question). Mark “no” if you do
If you are single and your assets (the total amount on Line
not own life insurance policies with a total face
38d of Form IL-1363) are $11,500 or less, you must
complete Schedule C. If your assets are greater than
value greater than $1,500, and go to Line 7.
$11,500, you do not need to complete Schedule C.
6b
Write the amount of money you would get if you
If you are married and living with your spouse and your
turned in your insurance policies for cash right
assets (the total amount on Line 38d of Form IL-1363) are
now. Cash value is different than the face
$23,000 or less, you must complete Schedule C. If your
value. (You may need to call your insurance
assets are greater than $23,000, you do not need to
company to help answer this question).
complete Schedule C.
7
If you plan to use all or part of your savings or
You must apply for “extra help” if you are eligible for
other resources to pay for your funeral and
Medicare (Part A and/or Part B) in order to qualify for
burial expenses, mark “yes”; otherwise, mark
Illinois Cares Rx. It is important that you complete your “extra
“no”. If you plan to use all or part of your
help” application and send it in for a decision even if you do not
savings or other resources to pay for your
think you will be eligible.
spouse’s funeral and burial expenses, mark
“yes”; otherwise, mark “no”.
Step 1: Tell us about yourself (claimant).
8
Mark the box to show the number of relatives
1 Social Security number
who live with you, and for whom you or your
Write your Social Security number (same as Line 1
spouse provide at least one-half of their
on Form IL-1363).
financial support. Mark “0” if you have no
relatives living with you, or if you do not provide
2 Name
at least one-half of their financial support.
Print your first name, middle initial, and last name.
9
Mark “yes” if you have experienced a decrease
in your Social Security, Railroad Retirement or
Step 2:
Tell us about your spouse
Veterans Administration benefits, other
pensions and annuities, or other income during
(husband or wife).
the last two years. Mark “no” if no decrease.
Complete Step 2 only if you checked Marital status 2,
“Married and living together”, on Line 7 of Form IL-1363.
Mark “yes” if your spouse has experienced a
Otherwise, if you do not have a spouse, if your spouse is
decrease in his or her Social Security, Railroad
deceased, or if you are not living in the same household
Retirement or Veterans Administration benefits,
with your spouse, go to Step 3.
other pensions and annuities, or other income
during the last two years. Mark “no” if no
3 Spouse’s Social Security number
decrease.
Write your spouse’s (husband’s or wife’s) Social
10a
Mark “yes”, if anyone provides or helps you or
Security number (same as Line 9 on Form IL-1363).
your spouse pay for your food, mortgage, rent,
4 Spouse’s name
heat, gas, electricity, water or property taxes.
Print your spouse’s first name, middle initial, and
Do not count food stamps, house repairs, help
last name.
from a housing agency (Section 8), an energy
assistance program, Meal on Wheels, or help
Step 3:
Complete the following
with medical treatments and drugs.
information about you and
Mark “no”, if no one provides or helps you or
your spouse
(if married and
your spouse pay for your food, mortgage, rent,
living together)
heat, gas, electricity, water or property taxes. If
you mark “no”, go to Line 11.
5
Mark “yes” if you own real estate other than your
home and the property on which your home is
located. Mark “no” if you do not own any other
real estate.
Schedule C instructions (IL-1363) (R-12/05)

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