I (eligible individual's name), for purposes of receiving such payments as I may be entitled to receive under the Nursing Home Grant Assistant Act, do hereby authorize (distribution agent's name) to disclose to the Illinois Department of Revenue that: | ||||||
My name is: | ||||||
; | ||||||
My Social Security Number is: | ||||||
; | ||||||
I am not a recipient of federal, State, or combined federal and State medical care program payments (other than Medicare Part B benefits); | ||||||
My Annual Adjusted Gross Income After Subtraction For Nursing Home Care Expenses not paid for, in whole or in part, by a federal, State or combined federal-State medical care program (other than Medicare Part B benefits), is: | ||||||
$ | ; and | |||||
I understand that the (distribution agent's name) is required to pay to the Department of Revenue a fee of $1.00 per occupied bed day after June 30, 1992 and before July 1, 1993, and that (distribution agent's name) is prohibited by law from passing on to me, or otherwise charging to me, directly or indirectly, the $1.00 fee. | ||||||
Signed: (eligible individual's signature) | ||||||
Eligible Individual's Printed Name | ||||||
Date: | ||||||
Such a statement shall be made for each eligible individual in the first quarter for which such individual becomes eligible to receive a Nursing Home Grant Assistance Act payment.
Ill. Admin. Code tit. 86, § 535.110