Form Il-1363 - Circuit Breaker Application - 2003 Page 2

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Step 4: Does your total income allow you to file this application?

Count the total number of persons you are reporting from Lines 2 and 10, and

if you are reporting qualified additional residents (see instructions), you must

include the number from Schedule B, Line 16. Write the total in the box. ......................

If “YES,” go to Step 5.

Did you write

in Box 27 and is Line 25 less than

$21,218?

$28,480?

Did you write

in Box 27 and is Line 25 less than

If “NO,”

. See Step 4 instructions,

Did you write

(or more) in Box 27 and is Line 25 less than

$35,740?

“Projecting your income.”

Step 5: Tell us about the Illinois property tax or rent you paid in 2003.

Property tax you paid in 2003

. .............................................

(total of both installments)

Mobile home tax you paid in 2003

. .............................................................

(yearly total)

Rent you paid in 2003

Does your rent include food?

yes

(yearly total).

a To whom did you pay rent in 2003?

Name __________________________________________ Phone (__ __ __) __ __ __ - __ __ __ __

Address ________________________________________ City_____________________ State_____ZIP________

b How many months did you rent here in 2003?

b______________

If you had more than one landlord, attach a sheet with the information requested on Lines 30, 30a, and 30b

above for each one.

Do not include amounts paid by a Section 8 program.

If you now live in public housing, but last year lived in private housing, see the instructions for Line 30.

Nursing, retirement, or shelter care home charges you paid in 2003

. ............

(yearly total)

a To whom did you pay nursing, retirement, or shelter care home charges in 2003?

Name __________________________________________ Phone (__ __ __) __ __ __ - __ __ __ __

Address ________________________________________ City_____________________ State_____ZIP________

b How many months did you live here in 2003?

b______________

If you lived in more than one nursing, retirement, or shelter care home, attach a sheet with the

information requested on Lines 31, 31a, and 31b above for each one.

Do not include any amounts paid by Human Services.

Step 6: 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 state of Illinois

permission to get records from anyone concerning information on this form. I also assign to the state of Illinois 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 or SeniorCare. I also agree that if I receive any such payments or other payments or benefits under

these programs in error, or that I was not entitled to, I will repay them to the state of Illinois. 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 the state of Illinois and any of my

physicians and pharmacists to the extent necessary for the operation of a drug utilization review service.

_________________________________/___/___

___________________________(____)________

Claimant’s signature

Date

Preparer’s name (Please print or type.)

Phone number

Do not send us any checks or money

_________________________________/___/___

with your application.

Spouse’s signature (If living together)

Date

If you need additional assistance

• visit our Web site at

Seniors, you may get help from the IL Dept. on Aging

• call us at 1 800 624-2459, or

• visit their Web site at

• call our TDD (telecommunications device for

• call the Senior HelpLine at 1 800 252-8966 (voice

the deaf) at 1 800 544-5304, or

and TYY)

If applying for ALL benefits - including

If ONLY applying for a grant or license plate discount

Pharmaceutical Assistance or SeniorCare

CIRCUIT BREAKER & DRUG COVERAGE

CIRCUIT BREAKER

ILLINOIS DEPT OF REVENUE

PO BOX 19022

PO BOX 19003

SPRINGFIELD IL 62794-9022

SPRINGFIELD IL 62794-9003

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.

IL-1363 back (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-492-2740

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