2011 Schedule C - Pharmaceutical Benefits - Illinois Department On Aging Page 2

Download a blank fillable 2011 Schedule C - Pharmaceutical Benefits - Illinois Department On Aging in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete 2011 Schedule C - Pharmaceutical Benefits - Illinois Department On Aging with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

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 ...........................................................................

Do you plan to use any of the savings or resources on Lines 11a, 11b and 11c, 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 14a, 14b, 14c, 14d, or 14e decreased in the last two years?

You: yes

Spouse (If living together): yes

You

Spouse

16 a

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 16a or 16b 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

Reset Form

2 of 2 • Schedule C / IL-1363 (R-12/11)