Form Il-1363 - Schedule B Qualified Additional Residents 2000
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1
2Illinois Department of Revenue
2000 Schedule B
Qualified Additional Residents
Attach to your 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 2000 and in 2001 at the time you file your 2000
Form IL-1363; and
• for whom you, or you and your spouse, provided more than half of that person’s total support
in 2000; and
• who is not filing a separate 2000 Form IL-1363.
Step 1:
Tell us about your qualified additional residents.
Please print.
Check “Yes” if applying for
1
Social Security number
5
Pharmaceutical
Assistance coverage.
2
Name______________________________________________
Yes
First
MI
Last
3
Birth date__ __/__ __/__ __ __ __
•
For Pharmaceutical Assistance coverage,
Month Day
Year
see instructions for eligibility requirements
4
Relationship to claimant _______________________________
and what you may need to attach.
Check “Yes” if applying for
6
Social Security number
10
Pharmaceutical
Assistance coverage.
7
Name______________________________________________
First
MI
Last
Yes
8
Birth date__ __/__ __/__ __ __ __
•
For Pharmaceutical Assistance coverage,
Month Day
Year
see instructions for eligibility requirements
9
Relationship to claimant _______________________________
and what you may need to attach.
Check “Yes” if applying for
11
Social Security number
15
Pharmaceutical
Assistance coverage.
12
Name______________________________________________
Yes
First
MI
Last
13
Birth date__ __/__ __/__ __ __ __
•
For Pharmaceutical Assistance coverage,
Month Day
Year
see instructions for eligibility requirements
14
Relationship to claimant _______________________________
and what you may need to attach.
Check “Yes” if applying for
16
Social Security number
20
Pharmaceutical
Assistance coverage.
17
Name______________________________________________
First
MI
Last
Yes
18
Birth date__ __/__ __/__ __ __ __
•
For Pharmaceutical Assistance coverage,
Month Day
Year
see instructions for eligibility requirements
19
Relationship to claimant _______________________________
and what you may need to attach.
Check “Yes” if applying for
21
Social Security number
25
Pharmaceutical
Assistance coverage.
22
Name______________________________________________
Yes
First
MI
Last
23
Birth date__ __/__ __/__ __ __ __
•
For Pharmaceutical Assistance coverage,
Month Day
Year
see instructions for eligibility requirements
24
Relationship to claimant _______________________________
and what you may need to attach.
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.
Failure to provide information could delay your grant and/or pharmaceutical coverage. This form has been approved by the Forms Management Center.
IL-492-4159
Schedule B front (IL-1363) (N-12/00)
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