Form Il-1363-X - Amended Application For Circuit Breaker And Pharmaceutical Assistance
ADVERTISEMENT
1
2Illinois Department of Revenue
IL-1363-X
Amended Application for
(For year __ __ __ __) Circuit Breaker and
Pharmaceutical Assistance
Official use only
Step 1: Tell us about yourself (claimant).
Please print.
1 Social Security number
6 Birth date __ __/__ __/__ __ __ __
Month
Day
Year
2 Name________________________________________________
7 Marital status
(
only one box.)
First
MI
Last
Single, widow(er), or divorced
1
3 Address___________________________________ Apt._______
Married and living together
2
City_______________________ State_____ ZIP______________
Married, but not living together
3
4 Phone (__ __ __) __ __ __ - __ __ __ __
Area code
5 You cannot apply for Pharmaceutical Assistance on this form (see instructions).
Step 2: Tell us about your spouse (husband or wife).
If none or deceased, go to Step 3.
8 Write your spouse’s Social Security number. ..... 8
9 Write your spouse’s name. ................................ 9 __________________________________________
First
MI
Last
10 Write your spouse’s birth date. ........................ 10 __ __/__ __/__ __ __ __
Month
Day
Year
11 Your spouse cannot apply for Pharmaceutical Assistance on this form (see instructions).
Step 3: Tell us your total income for the year for which you are filing this amended
application
(include both the claimant’s and spouse’s).
Income or losses
Correct
A
B
originally reported
income or losses
12
12
Social Security, SSI benefits. Include Medicare deductions (yearly total) . .
13
13
Railroad Retirement benefits. Include Medicare deductions (yearly total).
14
Civil Service benefits (yearly total). ........................................................... 14
15
15
Other pensions and annuity benefits (yearly total). .................................
16
16
Veterans’ benefits (yearly total). ................................................................
17
17
Human Services and other cash public assistance benefits (yearly total).
18
18
Wages, salaries, and tips from work (yearly total). _________+________ =
Claimant
Spouse
19
19
Interest and dividends received (yearly total). .........................................
20
20
Net rental, farm, and business income or (loss).
If loss, attach copy of U.S. 1040.
a Write the number of rooms in your home.
a__________
b Write the number of rooms you rented to someone else. b__________
21
21
Net capital gain or (loss). If loss, attach copy of U.S. 1040. ...................
22
22
Other income or (loss). If loss, attach copy of U.S. 1040. .......................
Step 4: Tell us your total income for the year for which
you are filing this amended application.
A
B
Originally reported
Correct amount
23
23
Add Lines 12 through 22. This is your total income. ..............................
24
Count the total number of persons you are reporting from
Lines 2 and 9, and if you are reporting qualified additional residents
Go to
(see instructions), you must include the number from Schedule B,
24
Step 5
Line 16. Write the total in the box. .........................................................
IL-1363-X front (R-12/01)
Page 1 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial