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Forms and Documents

  
 

IMOS Forms

- Online Death Reporting (Brother or Widow)

-  Matching Grant Application - Lodges Only

-  Age and Length of Membership

- Instructions for Completing Application for Assistance

- Application for Assistance

- Waiver

- Compliance Agreement

- Notice of Privacy Practices

- Consent for Release HIPPA

- Appeal Form

- Reassessment Form

- Widow Assistance

State of Illinois

- Online application for Extra Help Program

- Illinois Cares Rx Online Application IL-1363 Online Form

- BenefitsCheckUp Online

For assistance completing any of the forms above contact:

 Karla K. Carwile, MA, MA, LCPC, DCC
Director of Outreach Services
Grand Lodge of Illinois
2866 Via Verde    
Springfield, Illinois 62703 
Phone: 217-529-8900- ext 212    
Fax: 217-529-0242
 Toll Free 1-800-530-8856