Form Il-1363-X - Amended Application For Form Il-1363 Benefits
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1
2Illinois Department on Aging
20_ _ IL-1363-X
Amended Application for Form IL-1363 Benefits
Official use only
Step 1: Tell us about yourself (claimant).
Please print.
1 Social Security number
6 Birth date
__ __/__ __/__ __ __ __
Month
Day
Year
2
7 Marital status
Name________________________________________________
(
only one box.)
First
MI
Last
Single, widow(er), or divorced
1
3
Address___________________________________ Apt._______
Married and living together
2
City_______________________ State_____ ZIP______________
Married, but not living together
3
4 Phone
8 Are you Male
(__ __ __) __ __ __ - __ __ __ __
Female
Area code
5 You cannot apply for drug coverage on this form (see instructions).
Step 2: Tell us about your spouse (husband or wife).
If none or deceased, go to Step 3.
9 Write your spouse’s Social Security number. .... 9
10 Write your spouse’s name. .............................. 10
__________________________________________
First
MI
Last
__ __/__ __/__ __ __ __
11 Write your spouse’s birth date. ........................ 11
Month
Day
Year
12 Your spouse cannot apply for drug coverage on this form (see instructions).
Step 3: Tell us your total income for the year for which you are filing this amended
application
(include both the claimant’s and spouse’s).
Income or losses
Correct
A
B
originally reported
income or losses
13
13
Social Security, SSI benefits. Include Medicare deductions (yearly total) .
14
14
Railroad Retirement benefits. Include Medicare deductions (yearly total).
15
15
Civil Service benefits (yearly total). ..........................................................
16
16
Annuity benefits (yearly total). ..................................................................
17
17
Other pensions -- federally taxable portion only (yearly total). ...............
18
18
Veterans’ benefits -- federally taxable portion only (yearly total). ...........
19
19
Human Services and other cash public assistance benefits (yearly total).
20
20
Wages, salaries, and tips from work (yearly total).________+________=
Claimant
Spouse
21
21
Interest and dividends received (yearly total). ......................................
22
22
Net rental, farm, and business income or (loss).
If loss, attach copy of U.S. 1040.
23
23
Net capital gain or (loss). If loss, attach copy of U.S. 1040. ................
24
Other income, (loss) or (deductions). If loss or deductions, attach
24
copy of U.S. 1040. .................................................................................
25
25
Add Lines 13 through 24. This is your total income. ...........................
26
If you rented out any part of your home to someone else,
complete Lines 26a and 26b.
a Write the number of rooms in your home.
26a__________
b Write the number of rooms you rented to someone else.
26b__________
Go to
Step 4
IL-1363-X front (R-12/05)
Page 1 of 4
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