Form Il-1363 - Schedule B - Qualified Additional Residents - 2003
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Illinois Department of Revenue
2003 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 2003 and in 2004 at the time you file your 2003 Form IL-1363; and
•
for whom you, or you and your spouse, provided more than half of that person’s total financial support in 2003; and
•
who is not filing a separate 2003 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 2003, and that these individuals lived with me in the same residence in 2003 and in 2004 at the
time I file my 2003 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 Illinois
Department of Revenue (IDOR) permission to get records from anyone concerning information on this form. I also assign to IDOR 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 Pharmaceutical Assistance program. I also agree that if I receive any such payments or other payments or benefits under
this program in error, or that I was not entitled to, I will repay them to IDOR. 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 IDOR 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.
1
Avoid a delay
Apply by March 31
(R-12/03)
IL-1363 instructions (R-12/03)
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
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