Form Il-1363-X - Amended Application For Form Il-1363 Benefits (Page 2 of 2) in pdf

Step 4: Tell us how many persons you are reporting for the year

for which you are filing this amended 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 9. Write the total in the box. ...........................................................

Step 5: Tell us about the Illinois property tax or rent you paid in the year for which

you are filing this amended application.

Originally reported

Correct amount

Property tax you paid (total of both installments). .............................

Mobile home tax you paid (yearly total) . ...............................................

Rent you paid (yearly total). ..................................................................

Does your rent include food? .................. yes

a To whom did you pay rent?

Name __________________________________________Phone

(__ __ __) __ __ __ - __ __ __ __

Address

________________________________________City____________________State_____ZIP________

b How many months did you rent here?

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 previously lived in private housing, see the instructions for Line 30.

Nursing, retirement, or shelter care home charges

you paid (yearly total) . ...........................................................................

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

Name __________________________________________Phone

(__ __ __) __ __ __ - __ __ __ __

Address

________________________________________City____________________State_____ZIP________

b How many months did you live here?

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 authorize the Illinois Department of Revenue to disclose information from any of my

tax returns for the limited purpose of confirming my eligibility for benefits. As permitted by law, and subject to resource availability, I authorize the state of Illinois

to apply on my behalf for any federal drug benefits I may be eligible to receive under the Medicare program. I 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 Illinois Cares Rx program. I also agree that if I receive any such payments or other payments or benefits under the programs on

this form 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

______________________________________/___/___

Spouse’s signature (If living together)

Date

Mail your completed form to us

If you need additional assistance

• visit our Web site at

CIRCUIT BREAKER

• to find a local agency serving seniors, call the Senior

ILLINOIS DEPT ON AGING

HelpLine at 1-800-252-8966

PO BOX 19003

• call us at 1-800-624-2459, or

SPRINGFIELD IL 62794-9003

• call our TTY at 1-800-544-5304

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.

Failure to provide information could delay your grant and/or prescription coverage. This form has been approved by the Forms Management Center. IL-402-1098

IL-1363-X back (R-12/05)

Page 2 of 4

Form Il-1363-X - Amended Application For Form Il-1363 Benefits Page 2

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