Tax And Rent Refund Application - Maine Revenue Services - 2002
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1
2020372000
Tax and Rent Refund Application
Maine
Low-Cost Drug Program Application/Renewal
Revenue Services
PO Box 9116
Augusta, Maine 04332-9116
to each question for
Do not use red ink.
YOUR REFUND OR DRUG CARD WILL
Use blue or black ink.
BE DELAYED IF YOUR APPLICATION IS NOT COMPLETE.
Are you now a Maine resident? ............................ a.
Do you receive State Supplemental Income? ........... b.
Do you receive full MaineCare (formerly
1. Your First Name
M.I.
Medicaid) benefits? ................................................ c.
Do you receive any federal disability payments
Your Last Name
(including social security disability)? ..................... d.
Are you disabled based on social security
standards? ............................................................... e.
Your Social Security Number
Your Date of Birth
Were you a Maine resident for all of 2001? ......... f.
-
-
-
-
Did you have a home or apartment in Maine for
Month
Day
Year
all of 2001 and live in your home or apartment
for at least 6 months of 2001? ............................... g.
Ù
2. Spouse’s First Name
M.I.
Is your spouse now a Maine resident? .................. a.
Does your spouse receive State Supplemental
Spouse’s Last Name
Income? .................................................................... b.
Does your spouse receive full MaineCare
Spouse’s Social Security Number
Spouse’s Date of Birth
(formerly Medicaid) benefits? .............................. c.
-
-
-
-
Does your spouse receive any federal disability
payments (including social security disability)? ..... d.
Month
Day
Year
Is your spouse disabled based on social security
Ù
standards? ............................................................... e.
3. Mailing Address (include your apartment number)
4. City, Town or Post Office
State
Telephone Number
Zip Code
-
-
(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.
Does this dependent receive State Supplemental
Dependent’s First Name
Income? .................................................................... a.
Does this dependent receive full MaineCare
Dependent’s Last Name
(formerly Medicaid) benefits? .............................. b.
Does this dependent receive any federal disability
Dependent’s Social Security Number
Dependent’s Date of Birth
payments (including social security disability)? ..... c.
-
-
-
-
Is this dependent disabled based on social
security standards? ................................................. d.
Month
Day
Year
Does this dependent receive State Supplemental
Dependent’s First Name
Income? .................................................................... a.
Does this dependent receive full MaineCare
Dependent’s Last Name
(formerly Medicaid) benefits? .............................. b.
Does this dependent receive any federal disability
Dependent’s Social Security Number
Dependent’s Date of Birth
payments (including social security disability)? ..... c.
-
-
-
-
Is this dependent disabled based on social
security standards? ................................................. d.
Month
Day
Year
Turn page over and fill out other side
Printed under Approp. 010 18F 1384.01
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