Form Il-1363-X - Amended Application For Circuit Breaker And Pharmaceutical Assistance - Instructions
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2Instructions for Form IL-1363-X , Amended Application for
Circuit Breaker and Pharmaceutical Assistance
You may only file a Form IL-1363-X for years 1997 and
after.
For each line on which the figure in Column B is
different than in Column A, you must send us the
Who files a Form IL-1363-X?
documentation listed below.
Anyone who filed Form IL-1363 and needs to make
corrections must file Form IL-1363-X.
Line 12 - If the amount you are reporting in Column B is
different than Column A, you must send us a copy of Form
How do I apply for Pharmaceutical Assistance
SSA-1099, Social Security Benefits, showing the amount in
for myself, spouse, or qualified additional
Social Security benefits you received (including Medicare
deductions) and/or a statement from the Social Security
residents?
Administration showing any Supplemental Security Income
If you did not request Pharmaceutical Assistance on your
(SSI) you received.
original Form IL-1363, and you, your spouse, or qualified
additional residents wish to apply for Pharmaceutical
Line 13 - If the amount you are reporting in Column B is
Assistance, please call toll free 1 800 624-2459 or
different than Column A, you must send us written proof
TDD 1 800 544-5304.
from Railroad Retirement showing the amount in benefits
you received (including Medicare deductions).
Step-by-Step Instructions
Line 14 - If the amount you are reporting in Column B is
different than Column A, you must send us written proof
from Civil Service showing the amount in benefits you
Step 1: Tell us about yourself (claimant).
received.
Complete with your current information.
Line 15 - If the amount you are reporting in Column B is
Step 2: Tell us about your spouse.
different than Column A, you must send us a copy of your
Complete with your spouse’s current information.
annual statement showing both your taxable and nontaxable
income you received from any annuity, endowment, life
Step 3: Tell us your total income for the year
insurance or similar contract or agreement, IRAs, IRAs
for which you are filing this application
converted to Roth IRAs, and pensions.
(include both the claimant’s and spouse’s).
Line 16 - If the amount you are reporting in Column B is
Complete Column A using the figures you wrote on the
different than Column A, you must send us a copy of your
Form IL-1363 that you already filed. Take these figures from
annual statement from the Veterans Administration showing
the copy of the IL-1363 that you kept for your personal
both taxable and nontaxable benefits.
records. If you did not keep a copy and do not know what
you originally reported, leave Column A blank.
Line 17 - If the amount you are reporting in Column B is
different than Column A, write the total amount in Human
Complete Column B with your corrected figures. If you are
Services or other governmental cash public assistance
not correcting a number write the amount from Column A.
benefits you received. (It is not necessary to contact the
Human Services office to obtain this information.)
Example of how to report a corrected amount:
If you reported on Line 12 of your originally filed Form IL-
1363 that you received $12,000, but you now have received
Line 18 - If the amount you are reporting in Column B is
different than Column A, you must send us a copy of all of
an additional statement showing that you actually received
$15,500, you need to file an amended Form IL-1363-X. You
your W-2 forms (Wage and Tax Statement) furnished by all
your employers and a copy of your Form U.S. 1040.
would complete Line 12 on Form IL-1363-X like this:
Column A
Column B
Line 19 - If the amount you are reporting in Column B is
$12,000
$15,500
different than Column A, you must send us a copy of your
statements of interest and dividend income received from all
Example of how to report an amount that did not
sources.
change:
If your Line 13 did not change from the amount you
Line 20 - If the amount you are reporting in Column B is
reported on your originally filed Form IL-1363, you would
different than Column A, you must send us a copy of your
complete Line 13 on Form IL-1363-X like this:
federal income tax return and any supporting federal
schedules. If you did not file a federal return, you must
Column A
Column B
attach other proof showing the nature and amount of each
$1,000
$1,000
change in income or loss.
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Parent category: Financial