2011 Schedule C - Pharmaceutical Benefits - Illinois Department On Aging
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State of Illinois
Illinois Department on Aging
2011 Schedule C
Pharmaceutical Benefits
Attach to the claimaint’s Form IL-1363.
If you marked “no” on Line 34 of Form IL-1363, you must complete Schedule C if you or your spouse are eligible for
Medicare and want help paying for prescription drugs through Illinois Cares Rx. Parties to a civil union must each file a
separate Schedule C.
Step 1: Tell us about yourself (claimant) and your spouse.
Please print.
1 a
b
Claimant’s Social
Claimant’s
Security number
Birth date
Month
Day
Year
2 a
only one box)
e
Claimant’s Name
______________________________
Marital status (
First
MI
Last
Single, widow(er), or divorced
1
b
Address
_______________________ Apt.___________
Married and living together
2
Married, but not living together
3
c
City
_________________ State____
ZIP
____________
d
Phone
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
3 a
b
Spouse’s Social
Spouse’s
Security number
Birth date
Month
Day
Year
4
Spouse’s Name
__________________________________
First
MI
Last
Step 2: Complete the following information about you and your spouse
(if married and living together).
5
Did you work in 2011 or 2012?
F
F
F
F
You:
yes
no
Spouse (If living together):
yes
no
6
List your expected wages before taxes in 2012. If none, place a zero in the space.
You:
Spouse (If living together):
7
If self-employed, list your expected net earnings or losses in 2012. If none, place a zero in the space.
You:
Spouse (If living together):
F
F
8
Have any of the amounts you listed on Lines 6 or 7 decreased in the last two years?
yes
no
9
If you recently stopped working or plan to stop working, enter the month and year.
You:
___ ___ / ___ ___ ___ ___
Spouse (If living together):
___ ___ / ___ ___ ___ ___
How many relatives live with you and depend on you or your spouse for at least one-half of their
10
financial support? If none, place a zero in the space. Do not count yourself or your spouse. .................
Go to page 2 - Schedule C
This form is authorized as outlined by the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act.
IOCI 0853-11
Disclosure of this information is REQUIRED. Failure to provide information could delay your grant and/or prescription coverage.
IL-402-1096
Schedule C / IL-1363 (R-12/11) • 1 of 2
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