Form Il-1363 - Application For Circuit Breaker

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 9. Write the total in the box. ......................

Did you write

in Box 27 and is Line 25 less than

$21,218?

If yes, go to Step 5.

Did you write

in Box 27 and is Line 25 less than

$28,480?

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 2005.

Property tax you paid or was payable in 2005

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

(total of both installments)

Mobile home tax you paid in 2005

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

(yearly total)

Rent you paid in 2005

Does your rent include food?

yes

(yearly total).

a To whom did you pay rent in 2005?

Name

__________________________________________

Phone

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

Address

________________________________________ City________________________ State____ ZIP_________

b How many months did you rent here in 2005?

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 2005

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

(yearly total)

a To whom did you pay nursing, retirement, or shelter care home charges in 2005?

Name

__________________________________________

Phone

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

Address

________________________________________ City________________________ State____ ZIP_________

b How many months did you live here in 2005?

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: For your prescription drug benefits only.

You must complete the following information if you want help paying for prescription drugs.

Are you a

U.S. citizen or

qualified noncitizen?

You may still get some drug coverage, a grant, and a license plate discount even if no box is checked above.

If no, go to

Are you eligible for Medicare for your hospital or doctor expenses? yes

Line 34.

a If “yes,” have you applied for prescription benefits with a Medicare Part D

Prescription Drug Plan? yes

b If you have applied for a Medicare Part D Prescription Drug Plan, what is the name of your plan?

United AARP MedicareRx

OSF Health Plans

PacifiCare Saver Plan

WellCare

Health Alliance

Other:

______________________________

c Have you applied for “extra help” available under Medicare Part D? yes

If you qualify for the Illinois Cares Rx benefit and you have other health insurance that pays for

prescription drugs, you can choose to receive a $25 monthly rebate instead of receiving help paying for

prescriptions.

a Do you have other health insurance that pays for prescription drugs? yes

If no, go to

b If “yes,” do you want to receive the $25 monthly rebate instead of receiving help paying for

Step 7.

your prescriptions? yes

IL-1363 2 of 4(R-12/05)

Form Il-1363 - Application For Circuit Breaker - 2005 Page 2

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