Form Il-1363 - Schedule B - Qualified Additional Residents - 2004

Illinois Department on Aging

2004 Schedule B

Qualified Additional Residents

Attach to claimant’s Form IL-1363.

Who is a qualified additional resident?

A qualified additional resident is an individual, other than your spouse,

•

who lived with you in the same residence in 2004 and in 2005 at the time you file your 2004 Form IL-1363; and

•

for whom you, or you and your spouse, provided more than half of that person’s total financial support in 2004; and

•

who is not filing a separate 2004 Form IL-1363.

Step 1: Tell us about your qualified additional residents.

Please print.

Check “Yes” if applying for

1

5

Social Security number

Pharmaceutical Assistance

drug coverage.

Yes

2

Name _________________________________________________

First

MI

Last

Attach proof of age (first-time filer).

3

Birth date__ __/__ __/__ __ __ __

If the person listed in Line 2 is

Month

Day

Year

younger than 65 years of age and

the box in Line 5 is checked, attach

4

Relationship to claimant___________________________________

proof of disability.

Check “Yes” if applying for

6

10

Social Security number

Pharmaceutical Assistance

drug coverage.

7

Name _________________________________________________

Yes

First

MI

Last

Attach proof of age (first-time filer).

8

Birth date__ __/__ __/__ __ __ __

If the person listed in Line 7 is

Month

Day

Year

younger than 65 years of age and

the box in Line 10 is checked,

9

Relationship to claimant___________________________________

attach proof of disability.

Check “Yes” if applying for

11

15

Social Security number

Pharmaceutical Assistance

drug coverage.

12

Name _________________________________________________

Yes

First

MI

Last

Attach proof of age (first-time filer).

13

Birth date__ __/__ __/__ __ __ __

If the person listed in Line 12 is

Month

Day

Year

younger than 65 years of age and

14

Relationship to claimant___________________________________

the box in Line 15 is checked,

attach proof of disability.

Attach additional sheets if necessary.

Step 2: Figure the total of your qualified additional residents.

16

16

Write the total number of persons you are reporting in Step 1.

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 financial support in 2004, and that these individuals lived with me in the same residence in 2004 and in 2005 at the time

I file my 2004 Form IL-1363.

17

18 ___ ___ ___ - ___ ___ - ___ ___ ___ ___

______________________________/___/___

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 state of Illinois

permission to get records from anyone concerning information on this form. I authorize the Illinois Department of Revenue to disclose information from any of

my tax returns for the limited purpose of confirming my eligibility for benefits. I also assign to the state of Illinois 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 Circuit Breaker Pharmaceutical Assistance programs. I also agree that if I receive any such payments or other payments or benefits

under these programs in error, or that I was not entitled to, I will repay them to the state of Illinois. 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 the state of Illinois and

any of my physicians and pharmacists to the extent necessary for the operation of a drug utilization review service.

19

21

______________________________/___/___

____________________________/___/___

Signature of person named on Line 2

Date

Signature of person named on Line 12

Date

20

______________________________/___/___

Signature of person named on Line 7

Date

Schedule B (IL-1363)

This form is authorized as outlined by the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act. Disclosure of this information is REQUIRED.

(R-12/04)

Failure to provide information could delay your grant and pharmaceutical assistance coverage. This form has been approved by the Forms Management Center.

IL-492-4159