Form Il-1363 - Schedule B Qualified Additional Residents 2000 (Page 2 of 2) in pdf

Check “Yes” if applying for

Social Security number

Pharmaceutical

Assistance coverage.

Name______________________________________________

Yes

First

Last

Birth date__ __/__ __/__ __ __ __

•

For Pharmaceutical Assistance coverage,

Month Day

Year

see instructions for eligibility requirements

Relationship to claimant _______________________________

and what you may need to attach.

Check “Yes” if applying for

Social Security number

Pharmaceutical

Assistance coverage.

Name______________________________________________

First

Last

Yes

Birth date__ __/__ __/__ __ __ __

•

For Pharmaceutical Assistance coverage,

Month Day

Year

see instructions for eligibility requirements

Relationship to claimant _______________________________

and what you may need to attach.

Check “Yes” if applying for

Social Security number

Pharmaceutical

Assistance coverage.

Name______________________________________________

First

Last

Yes

Birth date__ __/__ __/__ __ __ __

•

For Pharmaceutical Assistance coverage,

Month Day

Year

see instructions for eligibility requirements

Relationship to claimant _______________________________

and what you may need to attach.

If you have more than 8 qualified additional residents, report the information required for each person (Lines 1-5) and

your name and Social Security number on a separate sheet of paper and attach it to your Form IL-1363.

Step 2:

Figure the totals of your qualified additional residents.

Write the number of persons you are reporting on this schedule. 41

How many of these persons are now applying for

Pharmaceutical Assistance coverage? ................................ 42

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 support in 2000, and that these individuals lived with me in the same residence in 2000 and in 2001 at the time I file my 2000 Form IL-1363.

43 ______________________________/___/___

44 ___ ___ ___- ___ ___-___ ___ ___ ___

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 Illinois

Department of Revenue (IDOR) permission to get records from anyone, including the Social Security Administration, concerning information on this form.

This consent includes my authorization for the Social Security Administration to release my Social Security number, name, date of birth, and payment

amounts for calendar years 2000, 2001, and 2002, for Circuit Breaker and Pharmaceutical Assistance application processing. This consent is in effect until

such time as I withdraw my authorization. I also assign to IDOR 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 Pharmaceutical Assistance

program. I also agree that if I receive any such payments or other payments or benefits under this program in error, or that I was not entitled to, I will repay

them to IDOR. 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 IDOR and any of my physicians and pharmacists to the extent necessary for the operation of a

drug utilization review service.

45 ______________________________/___/___

49 ______________________________/___/___

Signature of person named on Line 2

Date

Signature of person named on Line 22

Date

46 ______________________________/___/___

50 ______________________________/___/___

Signature of person named on Line 7

Date

Signature of person named on Line 27