Instructions And Benefits Information For Form Il-1363 - Illinois Department Of Revenue - 2002 Page 17
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20You may need to attach...
Please write your name and Social Security number on each attachment.
Proof of your disability
Proof of age
If you are 16 years of age or older and totally
If you are the claimant or spouse or qualified
disabled, but younger than 65 years of age before
additional resident and you are applying for the first
January 1, 2003, and you are the
time, you must attach a copy of one of the following
examples as proof of age.
claimant, or
baptismal record
spouse or qualified additional resident who is
birth certificate
applying for Pharmaceutical Assistance
driver’s license
coverage,
ID card from the Illinois Secretary of State
you must attach one of the following as proof of
insurance policy
disability.
passport
If you received Social Security disability benefits
If you have not filed an approved Form IL-1363
(and you did not file an approved Form IL-1363
last year), you must send us one of the following:
since 1999, you are considered a first-time applicant.
a copy of Form SSA-1099 showing a Medicare
Proof of death
deduction
If you are a widow or widower who was 63 or 64
a copy of your statement showing SSI benefits
years of age before the death of your spouse (if your
a copy of your statement showing a Medicare
spouse was receiving or was eligible to receive
deduction
program benefits) and you do not qualify as
If you received Veterans Administration disability
disabled), you must attach a copy of your spouse’s
benefits, you must send us one of the following:
death certificate and proof of your age.
a copy of your pension statement
Proof of immigration status
a copy of your statement showing
compensation rated at 100 percent
If you are the claimant or spouse who is 65 years of
If you received Railroad Retirement or Civil
age or older (or who will become 65 years of age
Service disability benefits, you must send us
during 2003), not a U.S. citizen, and you checked
Box 1 in Line 5c or Line 12c, you must attach a copy
a copy of your pension statement from the
of one of the following examples as proof of your
Railroad Retirement or Civil Service agency
immigration status:
stating that you were totally disabled or you had
a deduction for Medicare.
• Alien Registration Receipt Card (I-151 or I-551)
If you had a Class 2 disability card from the
• Memorandum of Creation of Record of Lawful
Permanent Residence (I-181a)
Illinois Secretary of State’s office, you must send
us
• Arrival-Departure Record (I-94)
a copy of your Class 2 disability card as proof
Proof of your qualified additional
of your disability.
resident (Schedule B)
If you did not receive any of the above items, you
must send us
If you are reporting qualified additional residents, you
a completed Schedule A, Doctor’s Statement.
must attach Schedule B, Qualified Additional
(Use a separate Schedule A for each person.)
Residents. You must attach proof of that person’s
age. If you are applying for Pharmaceutical
If you are disabled and become 65 years old
Assistance for your qualified additional resident who
during 2003, we will prorate your grant and your
is younger than 65 years of age, attach proof of his
prescription coverage will become effective on or
or her disability.
after your birthday unless you send us proof of your
Your spouse is not a qualified additional
disability.
resident.
17
Avoid a delay
Apply by March 31
IL-1363 instructions (R-12/02)
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