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Lines 27 a - c - Write the name, address, and telephone

Line 20a - Write in the space provided the total

number of your landlord. Write in the spaces provided

number of rooms in your home.

the number of months during which you rented from this

Line 20b - Write in the space provided the number of

landlord and the amount in rent you paid to this landlord.

rooms you rented to someone else.

If you had more than one landlord, please attach

additional sheets with the above information for each

Line 21 - If the amount you are reporting in Column B is

landlord. On these attachments, please write your name

different than Column A, you must send us a copy of your

and Social Security number.

federal income tax return and any supporting federal

schedules. If you did not file a federal return, you must

If you now live at a residence that is not subject to

attach other proof showing the nature and amount of each

property taxes (such as public housing) but you did live

change in income or loss.

at a residence that was subject to property taxes (such

as private housing)during part or all of the year for which

Line 22 - If the amount you are reporting in Column B is

you are filing this amended application, you must send

different than Column A, you must send us a description of

us a copy of your rental agreement, lease, notarized

the nature of the income or loss reported and attach written

statement from your landlord, or cancelled checks to

proof.

document the rent you paid to the private landlord or a

copy of your tax bill. If you lived in more than one

Step 4: Tell us your total income for the

residence, you must also attach a letter stating the dates

year for which you are filing this

you lived at each residence.

amended application.

Line 28

If the amount you are reporting in Column B is different

Line 23

than Column A, you must send us a copy of the statement

Add the amounts in Column A, Lines 12 through 22, and

from your nursing, retirement, or shelter care home

write the total on Line 23, Column A.

showing the total amount you paid.

Add the amounts in Column B, Lines 12 through 22, and

Lines 28 a - c - Write the name and address of the

write the total on Line 23, Column B.

nursing, retirement, or shelter care home in which you

Line 24

lived. Write in the spaces provided the number of months

Do not complete Line 24 unless you are amending

during which you lived in this home and the amount in

Form IL-1363 for the year 2000.

charges you paid to this home. If you lived in more than

one home, please attach additional sheets with the

In Column A, write the number of persons you reported on

above information for each home. On these attachments,

Line 24 of Form IL-1363.

please write your name and Social Security number.

In Column B, write the number of persons you are

reporting on this Form IL-1363-X. If this number includes

Step 6: Sign below.

anyone other than yourself or your spouse, you must attach

Schedule B, Qualified Additional Residents.

Line 29

You (the claimant) must sign and date this form. See note

below.

Step 5: Tell us about the Illinois property

tax or rent you paid in the year for which

Line 30

you are filing this amended application.

If you are married and living with your spouse, your spouse

must sign and date Form IL-1363-X.

Line 25

If the claimant or claimant’s spouse is only able to

If the amount you are reporting in Column B is different

make a mark, another person must sign as a witness. If

than Column A, you must send us a copy of your property

the claimant or claimant’s spouse is unable to sign, the

tax bill or a statement from your mortgage company

form must be signed by the person’s a legal

showing the property tax you paid.

representative or person having power of attorney to act

on the person’s behalf. However, documentation must be

Line 26

to this form, proving that the representative is the

If the amount you are reporting in Column B is different

person’s legal representative or has power of attorney to

than Column A, you must send us a copy of your mobile

act on the person’s behalf. Applications without a valid

home tax bill.

signature or mark will not be approved.

Line 27

Line 31

If the amount you are reporting in Column B is different

Write the preparer’s name and phone number on this form.

than Column A, you must send us a notarized statement

If someone, other than you or your spouse, such as a son,

from your landlord or a copy of a lease agreement or

daughter, or legal representative, prepares this form for

cancelled checks showing the total amount in rent you paid.

you, that person should print or type his or her name and

We will not accept rent receipts. Do not include the amount

telephone number on Line 31.

paid by a Section 8 program. Check “yes” or “no” to indicate

whether your rent included food.

Form Il-1363-X - Amended Application For Circuit Breaker And Pharmaceutical Assistance - Instructions Page 2

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