Form Il-1363-X - Amended Application For Circuit Breaker And Pharmaceutical Assistance Page 2
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2Step 5: Tell us about the Illinois property tax or rent you paid in the year for which
you are filing this amended application.
A
B
Originally reported
Correct amount
25
25
Property tax you paid (both installments). ..........................................
26
26
Mobile home tax you paid (yearly total) . ...............................................
27
27
Rent you paid (yearly total). ..................................................................
Does your rent include food? .................. yes
no
a To whom did you pay rent?
Name __________________________________________Phone (__ __ __) __ __ __ - __ __ __ __
Address ________________________________________City____________________State_____ZIP________
b How many months did you rent here?
b______________
If you had more than one landlord, attach a sheet with the information requested on Lines 27a and 27b
above for each one.
Do not include amounts paid by a Section 8 program.
If you now live in public housing, but previously lived in private housing, see the instructions for Line 27.
28
Nursing, retirement, or shelter care home charges
28
you paid (yearly total) . ...........................................................................
a To whom did you pay nursing, retirement, or shelter care home charges?
Name __________________________________________Phone (__ __ __) __ __ __ - __ __ __ __
Address ________________________________________City____________________State_____ZIP________
b How many months did you live here?
b______________
If you lived in more than one nursing, retirement, or shelter care home, attach a sheet with the
information requested on Lines 28a and 28b above for each one.
Do not include any amounts paid by Human Services.
Step 6: Sign below.
Under penalties of perjury, I state that I have examined this form and, to the best of my knowledge, it is true, correct, and complete. I give the Illinois
Department of Revenue (IDOR) permission to get records from anyone concerning information I have placed on this form. I also agree that if I receive any
payments or other benefits under this program in error, or that I was not entitled to, I will repay them to IDOR.
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X
31
______________________________________/___/___
______________________________(___)________
Claimant’s signature
Date
Preparer’s name (Please print.)
Phone
30
X
______________________________________/___/___
Spouse’s signature (If living together)
Date
If you need additional assistance
ILLINOIS DEPT OF REVENUE/CIRCUIT BREAKER
• visit our Web site at
PO BOX 19003
SPRINGFIELD IL 62794-9003
• call us at 1 800 624-2459, or
• call our TDD (telecommunications device for the
deaf) at 1 800 544-5304
This form is authorized as outlined by the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act. Disclosure of this information is REQUIRED.
Failure to provide information could delay your grant and/or pharmaceutical coverage. This form has been approved by the Forms Management Center. IL-492-2743
IL-1363-X back (R-12/01)
Page 2 of 4
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Parent category: Financial