Form Il-1363 - Application For Circuit Breaker - 2005
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4State of Illinois
Rod R. Blagojevich, Governor
Illinois Department on Aging
2005 IL-1363
Application for Circuit Breaker and
Official use only
Step 1: Tell us about yourself (claimant).
Please print.
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6
Social Security number
Birth date
__ __/__ __/__ __ __ __
Month
Day
Year
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7
Name_______________________________________________
Marital status (
only one box)
First
MI
Last
Single, widow(er), or divorced
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3
Address__________________________________ Apt._______
Married and living together
2
City_______________________ State_____ ZIP_____________
Married, but not living together
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Phone
(__ __ __) __ __ __ - __ __ __ __
Are you
Male
Female
Area code
See instructions for
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Yes, I want help paying for my drugs.
more information.
Step 2: Tell us about your spouse (husband or wife).
Complete this step if you checked Marital status 2.
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Write your spouse’s Social Security number. .......
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Write your spouse’s name. .................................
_________________________________________
First
MI
Last
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Write your spouse’s birth date. ..........................
__ __/__ __/__ __ __ __
Month
Day
Year
12
Yes, I want help paying for drugs for my spouse.
See instructions for
more information.
Step 3: Write only the claimant’s and spouse’s total income for 2005.
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Social Security, SSI benefits. Include Medicare deductions (yearly total) ...........................
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Railroad Retirement benefits. Include Medicare deductions (yearly total) ...........................
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Civil Service benefits (yearly total) ...........................................................................................
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Annuity benefits (yearly total) ...................................................................................................
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Other pensions (yearly total) ................... a nontaxable
........... b taxable
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Veterans’ benefits (yearly total) ............... a nontaxable
........... b taxable
.
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Human Services and other cash public assistance benefits (yearly total) .............................
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+
Wages, salaries, and tips from work (yearly total)
=
Claimant
Spouse
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Interest and dividends received (yearly total) .........................................................................
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Net rental, farm, and business income or (loss). If loss, attach copy of U.S. 1040. .............
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Net capital gain or (loss). If loss, attach copy of U.S. 1040. ..............................................
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Other income, (loss) or (deductions). If loss or deductions, attach copy of U.S. 1040.
25 Add Lines 13 through 24. This is your total income.
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Do not include Lines 17a and 18a in your total.
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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.
a
_____________
b Write the number of rooms you rented to someone else. b
Postmark deadline for filing is December 31, 2006.
IL-1363 1 of 4 (R-12/05)
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