Form Il-1363 - Schedule A - Doctor'S Statement - 2003
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Illinois Department of Revenue
2003 Schedule A
Doctor’s Statement
Attach to the claimaint’s Form IL-1363.
You may need to complete Schedule A if you were younger than 65 years of age on January 1, 2004, and
•
you are the claimant, or
•
you are the claimant’s spouse or qualified additional resident who is applying for help paying for drugs.
Step 1:
Answer the following questions to determine if you should complete
this schedule.
1
Did you receive Social Security disability benefits in 2003?
Yes
No
2
Did you receive disability benefits from Railroad Retirement or Civil Service in 2003?
Yes
No
3
Did you receive disability benefits from the Veterans Administration in 2003?
Yes
No
4
Did you have a Class 2 disability card from the Illinois Secretary of State’s office in 2003? Yes
No
If you answered “yes” to any of the questions 1 through 4, stop. Do not complete this schedule, instead
see the instructions for what you may need to attach to Form IL-1363.
Step 2:
Complete the following information about yourself.
Please print.
Complete a separate Schedule A for each person and attach it to the claimant’s Form IL-1363, Circuit Breaker Application.
5
9
Social Security number
Birth date__ __/__ __/__ __ __ __
Month
Day
Year
6
10
Name_____________________________________________
Phone (__ __ __) __ __ __ - __ __ __ __
First
MI
Last
Area code
7
11
Address_________________________________ Apt.______
Claimant’s Social Security number
(from Line 1 of Form IL-1363)
8
City_________________________ State____ ZIP_________
Step 3:
A doctor must complete the following information about the person
named on Line 6.
The patient must meet the total disability criteria established by the Social Security Administration. Social Security
Administration guidelines do not include alcoholism or drug abuse as a qualification for disability status.
12
Patient’s name____________________________________________________________________
First
MI
Last
13
Date patient became disabled __ __/__ __/__ __ __ __
Month
Day
Year
14
Was the patient able to work for a living after the above date? Yes
No
15
Has the disability lasted or is it expected to continue for 12 months or more? Yes
No
16
What is the nature of the disability? ____________________________________________________
17
Doctor’s name_____________________________________________________________________
18
Doctor’s signature and date___________________________________________
__ __/__ __/__ __ __ __
Month
Day
Year
19
Doctor’s Illinois registration number 3 6 - ___ ___ ___ ___ ___ ___
(This number is issued by the Illinois Department of Professional Regulation.)
20
Doctor’s phone (__ __ __) __ __ __ - __ __ __ __
Area code
Schedule A (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-12/03)
Failure to provide information could delay your grant and prescription coverage. This form has been approved by the Forms Management Center.
IL-492-3691
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