Tax And Rent Refund Application - Maine Revenue Services - 2000
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1
2Tax and Rent Refund Application
Maine
Low-Cost Drug Card Application/Renewal
Revenue Services
2000
*000372000*
PO Box 1069
2000
Augusta, Maine 04332-1069
Do not use red ink.
BE SURE TO ANSWER “Yes” or “No” to each question for
Use blue or black ink.
each household member:
YOUR REFUND OR DRUG CARD
WILL BE DELAYED IF YOUR APPLICATION IS NOT COMPLETE.
a. Are you now a Maine resident? ............................. a.
Yes
No
1. Y our First Name
M.I.
b. Do you receive State Supplemental Income? .......... b.
Yes
No
c. Do you receive drug benefits from Medicaid? ..... c.
Yes
No
d. Do you receive any federal disability payments,
Your Last Name
(including social security disability)? ..................... d.
Yes
No
e. Are you disabled based on social security
Your Social Security Number
Your Date of Birth
standards? ................................................................ e.
Yes
No
-
-
-
-
f. Were you a Maine resident for all of 1999? ......... f.
Yes
No
Month
Day
Year
g. Did you have a home or apartment in Maine for
If applicant died during
–
–
all of 1999 and live in your home or apartment
1999 or 2000, enter date of death:
____
______
__________
for at least 6 months of 1999? ...............................g.
Yes
No
2. Spouse's First Name
M.I.
a. Are you now a Maine resident? ............................. a.
Yes
No
b. Do you receive State Supplemental Income? .......... b.
Yes
No
Spouse's Last Name
c. Do you receive drug benefits from Medicaid? ..... c.
Yes
No
d. Do you receive any federal disability payments,
Spouse's Social Security Number
Spouse's Date of Birth
(including social security disability)? ..................... d.
Yes
No
-
-
-
-
e. Are you disabled based on social security
standards? ................................................................ e.
Yes
No
Month
Day
Year
If spouse died during
–
–
1999 or 2000, enter date of death:
____
______
__________
3. Mailing Address
4. City, Town or Post Office
State
Telephone Number
Zip Code
-
-
5. Dependents. How many dependents do you have?
(DO NOT INCLUDE YOU OR YOUR SPOUSE.)
List your dependents below. If you have more than 2 dependents, list them on a separate sheet of paper.
Dependent's First Name
a. Does this dependent receive State Supplemental
Income? .................................................................... a.
Yes
No
b. Does this dependent receive drug benefits from
Dependent's Last Name
Medicaid? ............................................................... b.
Yes
No
c. Does this dependent receive any federal disability
Dependent's Social Security Number
Dependent's Date of Birth
payments, (including social security disability)? ..... c.
Yes
No
-
-
-
-
d. Is this dependent disabled based on social
Month
Day
Year
security standards? ................................................ d.
Yes
No
Dependent's First Name
a. Does this dependent receive State Supplemental
Income? .................................................................... a.
Yes
No
b. Does this dependent receive drug benefits from
Dependent's Last Name
Medicaid? ............................................................... b.
Yes
No
c. Does this dependent receive any federal disability
Dependent's Social Security Number
Dependent's Date of Birth
payments, (including social security disability)? ..... c.
Yes
No
-
-
-
-
d. Is this dependent disabled based on social
Month
Day
Year
security standards? ................................................ d.
Yes
No
Turn page over and fill out other side
Printed under Approp. 010 18F 1384.01
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